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Reflective practice in practice

2009; Elsevier BV; Volume: 13; Issue: 3 Linguagem: Inglês

10.1016/j.jbmt.2009.04.002

1532-9283

W. D. D. Mcneill,

Nursing Roles and Practices

This Prevention and Rehabilitation section continues with a theme started in its inaugural edition in January 2009 looking at taking information and applying it. This editorial discusses whether changes to the way he practices are likely, as a result of reflection, following the editor's’ reading of the two articles published in this section. Craig Liebenson's contribution to this edition on ‘plyometrics’ quickly adds weight at the end of the section! Successful rehabilitation work with a client can only start once a therapist knows enough about the injury or disability they are treating, and then more about the techniques within their field aimed at moving the client towards agreed goals. A therapist's success in preventative work, in my experience, actually comes after that, when the therapist starts to see regular patterns in the presentations of their client's problems. The development of knowledge about a specific client group, often due to a therapist's prior involvement in an activity or sport can help start a specialism within the therapist's practice. I am happy to lecture groups of Actors or Singers about the dangers of standing on raked stages, as I have seen so many of their profession with slow onset injuries, not necessarily so obviously associated with such a cause. Being able to discuss some of the details of the kinds of injuries I have treated in someone ‘just like them’ adds power to the ‘preventative’ message, and is stronger than reciting what one has learned from books. I am not quite that happy to discuss specific preventative points to a group involved in an activity I have had little contact with. I remember the glee with which a member of a ballet company recounted to me the story of a football physio who came to talk to the company about stretching. They had left him speechless by volunteering the bendiest girl in the company to be his model. Specialisation, in my view, are to be encouraged and indeed are the norm within the medical profession, but recognizing the pitfalls of specialisation is also important. One of the two Professional Bodies that I belong to, The Chartered Society of Physiotherapy, suggests that I should undertake a process called ‘Reflective Practice’ for my Continuing Professional Development (CPD). The Chartered Society of Physiotherapy's (CSP) website, on its public side, introduces Reflective Practice as “a process by which you stop and think about your practice, consciously analyse your decision making and draw on theory and relate it to what you do in practice.” And that it “refocuses your thinking on your existing knowledge and helps generate new knowledge and ideas. As a result, you may modify your actions, behaviour, treatments and learning needs.” I used to work with several Physiotherapists in a practice where we would have regular ‘in-service training’ lectures but fundamentally the onus on improving your knowledge base was a personal one and the key way to gain that information was via weekend courses, attendance at conferences, and reading articles or books—when that could be fitted in. I now operate in a different environment with members of other disciplines practicing alongside me, but similarly, each individual therapist or practitioner has to maintain their own professional standards and continuing education for themselves. The website of ‘Physio First’, the organisation of chartered physiotherapists in private practice, says they have approximately 4000 members, though I know that not all private practitioners are members. These are a small but significant proportion of the 48,600 quoted number of members (Chartered Society of Physiotherapy Annual Review, 2006Chartered Society of Physiotherapy Annual Review, 2006, p. 21.Google Scholar) of the United Kingdom's Chartered Society of Physiotherapists (which includes Students and Assistants). The private physiotherapists are probably the most likely group to be working on their own and have had to make it their responsibility to keep up to date. Newly graduating physiotherapists are now feeling the financial squeeze within the National Health Service (NHS) as many graduating members of our profession are not getting work, “80% of physiotherapy graduates still looking for their first NHS job this year.” (The Guardian, 7 November 2007). Another knock on effect of the financial squeeze is the budget for staff education being reduced. One health education company I know, specializing in physiotherapists have reported, quietly, to me, that their NHS market has bottomed out. This probably means more of my colleagues in the NHS are needing to take responsibility to provide their own CPD. There is now more to going on a course than just receiving a certificate of attendance. Since the 1st of July 2006 the UK's Health Professions Council (HPC), providing governmental registration to many health care groups, such as podiatrists, osteopaths and physiotherapists, has required its members to record its CPD, advises the HPC's website, including with it, a reflective component about how the new knowledge could change or affect the members practice of their profession. Reflective practice should not just be internal reflection but discussing subjects with peers or mentors is also to be encouraged. Austin et al., 2006Austin Z. Marini A. Glover N.M. Tabak D. Peer-mentoring workshop for continuous professional development.Am. J. Pharm. Educ. 2006; 15; 70: 117Crossref Scopus (11) Google Scholar showed that 69% of Canadian pharmacists found not to be meeting standards of practice were helped by a Peer-Mentoring workshop and able to pass a peer review rechallenge process after completing the workshop. If I start to review my practice critically I find it to be a very challenging thing. I have the fear that someone (or everyone) will find out that I do not know what I am talking about. I realize, by going through the process of writing this Editorial, that the way in which I now work does not encourage me to discuss my clinical decision-making process with true peers—as I work with others of different professions with different processes. I spend almost all of my client contact time working alone, not discussing my treatment plans with physiotherapy colleagues. I now see that this can allow poor habits to set in. I find that I have pet diagnoses that I want to pop everyone into. It is as if my diagnosis is a hammer and every client a potential nail. For example I seem to divide all my clients into 3 groups, those with ‘leather-like’ collagen—‘tight people,’ those with rubber-like collagen—‘loose people’ and ‘loose people with acquired tightness.’ It is those with the acquired tightnesses who usually have a positive slump test result, or increased upper limb neural tension, from postural or activity-led excesses, and are my pet diagnostic grouping. I recently had a client who presented before his referral letter arrived. He was classically a ‘loose person with acquired tightness’ with very shortened hamstrings protecting his irritated nervous system. He was limited in movement through the spine particularly at the cervico-thoracic and lumbo-pelvic junctions. I was very surprised when I later read the referral letter as it showed that I had not even considered the causative factor to be the suspected ankylosing spondylitis that the Consultant had identified for me to treat. I am sure I have good points to my practice too. I refer up or down the chain very quickly. I have recognized that a pitfall of the mild specialisations I have developed is that if I have areas I am very confident in, then likewise there are others in which I am not. For this I have developed a web of therapists, practitioners, doctors and consultants that I refer to, sometimes for a specific condition, others for their superior diagnostic skills. Still others, because I recognize they can treat a problem just better than I can. I recognize that I keep a constant spoken narrative going for the client's benefit, so they are aware of what I am reading in their posture or movement and its ramifications. I believe this communication is appreciated. I am aware that I am constantly monitoring the clients ‘comfort’ so I can alter my approach at a moments notice. No doubt all therapists experience the same worries, I am sure that even the neuro-musculo-skeletal guru's I look up to with such respect, have their days of worry about their own practice. Remember Laurence Olivier's words, “Don’t waste your time striving for perfection, instead, strive for excellence—doing your best.” Reflection, then, clearly is a tool to help you do your best. The following comments are not meant to be construed as a critical analysis or a judgment on the articles; more they are to show how the articles personally struck me and I wanted to reflect on them to see what, if any impact they are likely to have on my current practice. To make it easy I will refer to them by the key words in their title ‘Mirror’ and ‘Breathing.’ I chose these articles as they both have some interest for me and are related to things I do in my everyday practice. I am a physiotherapist who uses pilates exercise concepts and repertoire with probably 90 percent of the clients that I see. The use of breath is very important in how I work. I did work in my early career in respiratory wards and in Intensive Care, areas that should have made me very interested in breath, but it was not till I started pilates that I became so much more aware of the use of the stylized pilates breath and its options available in treatment. Including the option of using relaxed normal breathing during exercise not a stylized breath. I also have a large 2m×2m wall mirror in my treatment room and the cleaners are having to clean it every day as I have many clients placing their hands on it while they are holding their balance, or leaning on it while stretching, watching their bodies perform the task. My pre-conceived ideas are that the articles are going to tell me that good breathing techniques and the use of a mirror are fantastic tools. Immediately the abstract of ‘Mirror’ suggests that the use of a mirror does not necessarily enhance the performance of the motor skill tested. Oh no. In ‘Breathing’ I am reassured that the paper is going to be what I am expecting. I like using bio-feedback tools and have been known to like gadgets as well, perhaps this may identify for me a new gadget for the practice? Mirrors, I find out, may bias the visual system; well, I know that the visual system dominates in balance control following an ankle sprain and that low light anecdotally increases my client's incidence of recurrence. The paper suggests that the jury seems out on whether mirrors help in learned skill transference when practicing the newly acquired skill away from a mirror. The paper identifies weaknesses (subjective measures of performance) in some of the source references, meaning to me that the jury has gone out even further. What can I believe? At least the current authors want to be more objective in their study. ‘Breathing’ identifies we have not cured neck/back pain yet as it costs the US 90 billion dollars a year. Interesting to learn that problems with breathing and continence has a higher association with back pain than obesity and physical activity. Ah, I find they are quoting Hodges, Richardson, O’Sullivan – an Australian triumvirate – so this must be good stuff. I will suspend any criticism I may have developed. Hmmm, I know a little about overrecruitment of superficial muscles; so the external oblique references seems to be correct. A reminder of breathing physiology, good. Hypocapnia is identified to be low CO2 because of overbreathing. Interestingly I pull out from the table that Muscle suffers an increased membrane excitability during hypocapnia. The suggestion that hypocapnia may be related to musculo-skeletal status is very interesting. I can see why they may want to test it. A breathing assessment and intervention is itemized—it seems quite good. Mirror groups seem a little unequal to begin with but exclusions seem to bring them back to parity. Even I could repeat this study as the process is well explained. The two-dimensional mirror image of a person doing the test maneuver is likely to be better in one plane than another. That makes sense. The results highlight that a mirror does not always provide the feedback that you want, and that kinesthetic cues are also useful. So I see that the article is not really saying ‘don’t use a mirror’ as I originally feared that it might—rather it is saying that you should not just only use a mirror for teaching. I can live with that! That really reinforces how I work. I am impressed, the author in ‘Breathing’ has performed 300 trials. She seems convinced that a significant proportion (93%) of people with back or neck pain have direct links between their musculo-skeletal pain and their breathing (leading to hypocapnia), objective measures using the described piece of equipment were helpful in assessment, and in bio-feedback, and they were able to be improved by this approach. Sounds good. The conflict of interest note at the end gives me pause for thought. The graphs in the paper show the breathing she teaches her clients slows them down and is gently fuller. I can use other techniques in my toolkit to achieve that result such as getting the client to synchronise their breathing with mine, or deliver a stylized breath in a well-timed, well-paced pilates exercise. It is the awareness that I could think of the physiology of breathing having a direct effect on the neural and muscular systems that might be new, but perhaps I think it is more just a reminder to re-focus me. Both papers have helped reinforce my view of my practice. I may change a little on how much I use the mirror or think about the physiology of breath while delivering the same exercise prescription. And now I have recorded my reflections maybe I will be ready when the CPD assessors knock at my practice door.