Working through challenges: Clinical reasoning and critical

Reflection assists students in working through emotional perturbation, as seen in Section 4.4.1 and it also assists them in working through non-affective

challenges, such as time constraints or an unexpected occurrences. One might think that instrumental problem-solving need not be imbued with reflective thought. Yet, reflection plays a role in students’ in-the-moment reasoning (reflection-in-action) or problem-solving, and in making these moments into meaningful learning experiences after-the-fact (reflection-on-action). In the

introductory example of VRA (Section 1.2.3.2), this type of reflective process was exemplified. The data support that adaptation of procedures “in the moment” is a crucial element of practice invoking critical thinking and attention to individual client needs. This adaptation requires reflective capacity and is often described in student reflection. Students also reflect on missed opportunities for critical

thinking resulting in poor clinical reasoning.

Even early on, (including just after their first external placement), students are able to adapt procedures when necessary and also recognize these adaptations as valuable learning experiences. Students seem to learn from these situations that they need to be vigilant, to take nothing for granted. Students are able to articulate their clinical reasoning and demonstrate critical thinking through their reflection-on-action. For example:

I knew I could have asked my supervisor to take over the situation immediately but I thought it was an opportunity to challenge myself and decided to attempt to handle it on my own before seeking assistance. In order to keep the patient focused and alert, I had to modify the test procedure. I instructed the patient to raise his hand instead of pressing a button when he heard the tones and I presented some tones slightly louder than necessary in between thresholds searches. When I saw that the patient was still having difficulty staying focused on the task, I began to talk to him and ask him questions throughout the testing (e.g. “this one is going to be quieter so make sure you are listening carefully”, “don’t forget to raise your hand when you hear the sounds”). I also performed speech testing in between frequencies and shortened the Hughson-Westlake procedure whenever I felt confident that certain steps were not required to obtain accurate threshold estimations […] The test procedure modifications that I

utilized were not taught in the classroom (1004-1).

The idea of clinical scenarios that require students and new practitioners to work through a problem employing methods “not taught in the classroom” is prevalent in the data as an especially important opportunity and mechanism for learning. Several students suggest that working through such situations allows them to feel they have truly learned, in a meaningful and long-lasting way.

Confronting the time-constraints imposed by the realities of practice is a

frequently mentioned challenge early on in students’ clinical development. Yet, although reflection serves as a way of recognizing that working efficiently is an area in need of improvement (self-assessment) and perhaps that systems impose time-constraints (critical reflection), it is not apparent that reflection aids students in working more efficiently. Students name time constraints and

efficiency as a challenge and reflect upon how they manage the challenge, but do not explicitly demonstrate the utility of reflection to improve efficiency.

Implicitly, I posit that it is possible for reflection to improve efficiency indirectly, if reflection supports learning and development. For example, in the case of students recognizing when they are focusing on their own goals instead of

patient needs, reflection does demonstrate usefulness that may impact efficiency of care.

To reflect on instances of clinical reasoning in which critical thinking could have been employed is to turn that instance into a learning experience. For example, in two separate interviews, a clinical faculty/supervisor and a new

practitioner/former student recount the same example when probed for an example of an experience that demonstrated the importance of reflective practice.

The supervisor’s version:

… that's a chance to sit and listen, so I said “so what do you hear when you hear that”... then they stopped and they thought for a minute. "He's tired, and he's had enough." So I said "so when should you quit?" and the answer came back so they recognized before we get to that point. The problem they stated though was this: that they got inconsistent models. That they got one model that told them they had to do everything - and nobody's telling them you have to look at the patient. The didactic model, which is necessary in terms of gathering information, they weren't getting the part that says "okay, give the information he can take, give the information that meets the patient's needs" cuz once you hit that stressed out point, which was a 90-year-old man who was actually an ex- physician and very smart and quite comfortable with hearing aids to the extent that he wanted to use them [...]. Give him what he needs, don't give him what you think he needs. Or what you think he should need (2005-3-interview).

The new practitioner’s version (reflecting on this experience from when she was a student clinician):

...we kinda beat this poor guy like into a bush...like he was older...and he just by the end of it he was just like "oh like does everyone have this much trouble you know I don't mean to be such a pain" and we just kept going with him like we didn't realize he was being like "I'm exhausted. You need to let me go, this is too

much information." [...our supervisor] was kinda like "okay guys I think you've done enough let's regroup" and he was just kinda like "you know, I know you wanna get um the phone program turned up and fitting to targets properly and add those programs so he can hear in noise and um and get everything perfect and counsel on everything and using the telephone and make sure that's working well and make sure he knows how to use the remote and clean and take care of it and take the batteries out and like sometimes you just need to make sure he can turn the hearing aid on, he knows how to give it a clean, use the batteries, cuz you're gonna see him again in couple weeks. And that was his way of kinda telling you like...this is a bit too much for me like I'm at my limit I've had a bit too much I need to go home and let this digest." But, it was hard after having all those classes where it's like "fit it like this, and make sure he can do this, and talk on the phone, and talk about the listening devices and oh this is an idea too and you really gotta make sure you do this." But for [our supervisor] to just be like take a step back and just you need to listen what they're saying to you. Like they'll let you know how much they can handle [...] you need to accept that and respect that because [...] maybe you'll have to do a couple of follow-up

appointments with that person, but that's not a problem and that's gonna be okay, and you as the clinician need to be okay with that so that they can be okay with that as a client (1013-3-interview).

This example demonstrates this property of the reflection as a tool facet in several ways. In the moment, the clinical supervisor recognizes that the client was exhausted, but the students continue to adhere strictly to their preconceived model, or notions of a comprehensive appointment. The recognition of this example as one that required reflective capacity by both supervisor and student and their continued thinking about the example many months after it occurred, demonstrate the potential for both reflection-in-action and reflection-on-action to support critical thinking and clinical reasoning. I extend that reflection -in and -on -action act as tools to improve clinical reasoning and critical thinking, thus

4.4.5

Development of critical consciousness: Beginning to critically