Enhancing the human dimensions of children's neuromuscular care: piloting a methodology for fostering team reflexivity

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Distress in the care of people with chronic low back pain: insights from an ethnographic study

Introduction

Distress is part of the experiences and care for people with chronic low back pain. However, distress is often pathologised and individualised; it is seen as a problem within the individual in pain and something to be downplayed, avoided, or fixed. To that end, we situate distress as a normal everyday relational experience circulating, affecting, moving in, through, and across bodies. Challenging practices that may amplify distress, we draw on the theorisation of affect as a relational assemblage to analyse physiotherapy clinical encounters in the care of people with chronic low back pain.

Methods

Adopting a critical reflexive ethnographic approach, we analyse data from a qualitative project involving 15 ethnographic observations of patient-physiotherapist interactions and 6 collaborative dialogues between researchers and physiotherapists. We foreground conceptualisations of distress- and what they make (im)possible-to trace embodied assemblage formations and relationality when caring for people with chronic low back pain.

Results

Our findings indicate that conceptualisation matters to the clinical entanglement, particularly how distress is recognised and navigated. Our study highlights how distress is both a lived experience and an affective relation-that both the physiotherapist and people with chronic low back pain experience distress and can be affected by and affect each other within clinical encounters.

Discussion

Situated at the intersection of health sociology, sociology of emotions, and physiotherapy, our study offers a worked example of applying an affective assemblage theoretical framework to understanding emotionally imbued clinical interactions. Viewing physiotherapy care through an affective assemblage lens allows for recognising that life, pain, and distress are emerging, always in flux. Such an approach recognises that clinicians and patients experience distress; they are affected by and affect each other. It demands a more humanistic approach to care and helps move towards reconnecting the inseparable in clinical practice-emotion and reason, body and mind, carer and cared for.

How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis

Pain is a multidimensional experience. Physiotherapy has attempted to enhance earlier biomedical approaches to patient care through approaches like the 'biopsychosocial' model. Nevertheless, physiotherapy continues to focus on biomedical and/or behavioural aspects of care. We critically investigated how physiotherapists attend to human (psychosocial, emotional, existential, and moral) aspects of low back pain care. We co-analysed ethnographic data with researchers, patients, and physiotherapists using concepts of conforming, tinkering and abandoning 'scripts'. Data included observations of 28 physiotherapy interactions between 26 patients and 10 physiotherapists and 7 researcher-clinician dialogues. Analysis suggests when conforming to scripts, clinicians have difficulty recognising and responding to emotions; time pressure limited clinicians focus, and a biological focus often distracted from psychosocial aspects of people's back pain experiences. In contrast, tinkering with or abandoning scripts allowed space to broaden the focus. Drawing from theorists such as Butler (1999) and Gibson et al. (2020) our analysis contributes to health sociology, arguing that 'tinkering' with or 'abandoning' scripts can foster more humanistic, flexible and reflexive approaches to care. Although health sociologists have explored tinkering, abandoning is new; within physiotherapy, it encapsulates being able to respond with agility to non-physical elements of care without constraint from traditional ways of thinking and doing.

Teaching critical reflection in health professions education with transformative-vygotskian praxis

Reflective practice is a complex concept to adequately describe, communicate about and, ultimately, teach. Unrelieved tensions about the concept persist within the health professions education (HPE) literature owing to reflection's diverse theoretical history. Tensions extend from the most basic, e.g., what is reflection and what are its contents, to the complex, e.g., how is reflection performed and whether it should be evaluated. Nonetheless, reflection is generally seen as vital to HPE, because it imparts crucial strategies and awareness to learners in their professional practices. In this article, we explore both conceptual and pedagogical dimensions of teaching for reflection. We address the concept of reflection, its application to practice, and how to remain faithful to transformative, critical pedagogy when teaching for it. We present (a) an analysis of two theories of education in HPE: Transformative Learning and Vygotskian Cultural Historical Theory. We (b) outline a pedagogical approach that applies Piotr Gal'perin's SCOBA: schema for the complete orienting basis of an action. We then employ (a) and (b) to provide affordances for developing materials for educational interventions across HPE contexts.

Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society

Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward critically reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally-whether alone or together-requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Examining the Impact of Dialogic Learning on Critically Reflective Practice

PURPOSE

While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies.

METHOD

In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective.

RESULTS

The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences.

CONCLUSIONS

The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

The ubiquity of uncertainty in low back pain care

Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Therapeutic relationships in aphasia rehabilitation: Using sociological theories to promote critical reflexivity

BACKGROUND

Therapeutic relationships are fundamental in aphasia rehabilitation, influencing patient experience and outcomes. While we have good understandings of the components of therapeutic relationships, there has been little exploration of how and why therapists construct and enact relationships as they do. Sociological theories may help develop nuanced understanding of the values, assumptions and structures that influence practice, and may facilitate critical reflexivity on practice.

AIMS

To explore the potential for theoretical approaches from outside speech-language therapy to enable a deeper understanding of the nature and enactment of therapeutic relationships in aphasia rehabilitation.

METHODS & PROCEDURES

An explanatory single case study of one speech-language therapist-patient dyad in an in-patient stroke rehabilitation setting. Data included observations of five interactions, two interviews with the client and three interviews with the speech-language therapist. Analysis was guided by analytical pluralism that applied aspects of three sociological theories to guide data analysis and make visible the contextual factors that surround, shape and permeate the enactment of therapeutic relationships.

OUTCOMES & RESULTS

The analysis of this dyad made visible individual, interactional and broader structural features that illustrate the dynamic processes that practitioners and patients undertake to enact therapeutic relationships. Clinical practice could be viewed as a performance with each person continually negotiating how they convey different impressions to others, which shapes what work is valued and foregrounded. The patient and therapist took up or were placed in different positions within the interactions, each with associated expectations and rights, which influenced what types of relationships could, or were likely to, develop. Organizational, rehabilitation and individual practitioner structures assigned rules and boundaries that shaped how the therapist developed and enacted the therapeutic relationship. Whilst the therapist had some agency in her work and could resist the different influencing factors, such resistance was constrained because these structures had become highly internalized and routinized and was not always visible to the therapist.

CONCLUSIONS & IMPLICATIONS

While therapists commonly value therapeutic relationships, social and structural factors consciously and unconsciously influence their ability to prioritize relational work. Sociological theories can provide new lenses on our practice that can assist therapists to be critically reflexive about practice, and to enact changes to how they work to enhance therapeutic relationships with clients. What this paper adds What is already known on the subject Therapeutic relationships are critical in aphasia rehabilitation. We have a good understanding of the different components of therapeutic relationships and how relationships are perceived by patients and practitioners. What this paper adds to existing knowledge This study is novel in its use of sociological lenses to explore contexts and complexities inherent in building and maintaining therapeutic relationships. These are often invisible to the practitioner but can have a significant impact on how relational work is enacted and what forms of relationship are possible. What are the potential or actual clinical implications of this work? This study will support clinicians to critically reflect on how they enact therapeutic relationships and may enhance awareness of the often-hidden factors which influence the ways in which they work.

Critically reflective practice and its sources: A qualitative exploration

CONTEXT

Critical reflection may improve health professionals' performance of the social roles of care (eg collaboration) in indeterminate zones of practice that are ambiguous, unique, unstable or value-conflicted. Research must explore critical reflection in practice and how it is developed. In this study, we explored what critical reflection consisted of in a context known for indeterminacy, and to what sources participants attributed their critically reflective insights and approaches.

METHODS

The study context was the interface between health care and education for children with chronic conditions or disabilities necessitating health-related recommendations and supports (eg accommodations or equipment) at school. We conducted a secondary analysis of 42 interview transcripts from an institutional ethnographic study involving health professionals, school-based educators and parents of children with chronic conditions or disabilities. We coded all transcripts for instances of critical reflection, moments that seemed to lack but could benefit from critical reflection, and participant-attributed sources of critically reflective insights.

RESULTS

Critically reflective practice involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicating workarounds (ie strategies to circumvent imperfect systems), seeing inequities, and advocating as collaborators, not adversaries. Participants invariably attributed critically reflective insights to personal experiences such as former careers or close personal relationships.

CONCLUSIONS

This study shows that personal experiences and connections inspire critically reflective views, and that being critically reflective is not a binary trait possessed (or not) by individuals. It is learnable through personally meaningful experiences. Health professions education could aim to preserve philosophical space for personal experience as a source of learning and integrate evidence-informed approaches to foster critically reflective practice.

Cheer* in Health Care Practice: What It Excludes and Why It Matters

Clinicians' positive demeanor and "strengths based" focus can include working to create a cheerful atmosphere in health care environments, cheering for improvements in assessment outcomes, and cheering up clients in situations of decline. Drawing from philosopher Karen Barad's theories of inclusions and exclusions, we investigated what comes to matter (and what is excluded from mattering) when there is cheerfulness, cheering, and so forth (cheer*) in the day-to-day practices of a neuromuscular clinic. We worked collaboratively with clinicians, young people with Duchenne muscular dystrophy, and their families to co-examine the clinic in three iterative exploratory method spaces: (a) group "dialogues" with clinicians; (b) consultative interviews with children, families, and clinicians; and (c) transdisciplinary research team analysis sessions. Cheer* made some things matter in the clinic ("normal" physical function, "positive" emotions, test scores, compliance); and excluded others (grief and loss, "non-normative" bodies and lives, alternative practices, embodied knowledge). We discuss implications across health care settings.

The Divergence and Convergence of Critical Reflection and Critical Reflexivity: Implications for Health Professions Education

As a field, health professions education (HPE) has begun to answer calls to draw on social sciences and humanities (SS&H) knowledge and approaches for curricular content, design, and pedagogy. Two commonly used SS&H concepts in HPE are critical reflection and critical reflexivity. But these are often conflated, misunderstood, and misapplied. Improved clarity of these concepts may positively affect both the education and practice of health professionals. Thus, the authors seek to clarify the origins of each, identify the similarities and differences between them, and delineate the types of teaching and assessment methods that fit with critical reflection and/or critical reflexivity. Common to both concepts is an ultimate goal of social improvement. Key differences include the material emphasis of critical reflection and the discursive emphasis of critical reflexivity. These similarities and differences result in some different and some similar teaching and assessment approaches, which are highlighted through examples. The authors stress that all scientific and social scientific concepts and methods imported into HPE must be subject to continued scrutiny both from within their originating disciplines and in HPE. This continued questioning is core to the ongoing development of the HPE field and also to health professionals' thinking and practice.