Failure in Clinical Education: Using Mindfulness as a Conceptual Framework to Explore the Lived Experiences of 8 Physical Therapists

Abstract

INTRODUCTIONClinical education requires a seamless transition from classroom to clinic1. However, some students struggle to integrate affective domain skills and have difficulty applying generic abilities1 during real-time patient care. abilities include interpersonal skills, professionalism, stress management, and commitment to learning. These can be difficult to measure and even more difficult for faculty members to talk about.1 In response to these deficits, Wolff-Burke2 and colleagues3 coined the term Generic Inabilities to describe unprofessional behaviors of student physical therapists (PTs). These behaviors included poor communication, lack of interest, arrogance, irresponsibility, poor patient rapport, unresponsiveness to clinical instructor (Cl) feedback, and poor critical thinking during patient care.3 To date, it remains unknown how students think as they near failure, how they conceptualize it, and how they reemerge to find success and graduate.In response to similar concerns,4 ' physician educators815 developed mindful practice, defined as a purposeful awareness of one's internal affective states, practiced regularly, to enhance the intrapersonal relationship with oneself.14'18 This internal relationship has a direct influence on performance because it provides immediate information about emotions.9,11,18 The opposite of mindfulness is mindlessness, characterized by multitasking, self-deception, covering up deficiencies, excessive reliance on facts, excessive speed, and reactivity.10'12,16 While mindfulness has been added to the formal curriculum in medical training,13 occupational therapy,19'21 and psychology,12,22 little direct application has been studied in the field of physical therapist education.The purpose of this phenomenological study was to explore the personal accounts of 8 physical therapists that failed a graduate school clinical education course, remediated, and graduated successfully. Given the context of mindfulness theory and practice, research questions inquired whether mindless thoughts, feelings, and behaviors occurred prior to failure (Appendix A), and whether mindful thoughts, feelings, and behaviors occurred after remediation and success (Appendix B).LITERATURE REVIEWDistinctions Between Reflective Practice and Mindful PracticeSome authors conflate reflection in action with mindful practice. Schon23 first described reflection in action as appraising or thinking about an activity while engaged in it,23' 25 whereas Epstein10,11,14,13 defined mindful practice as a purposeful awareness of internal affective states. Both, therefore, encourage students to examine their own values and beliefs, formulate thoughtful questions, and consider the health care environment as a whole.25 However, despite some apparent commonalities, there are distinct differences between them.Functional MRI studies26,27'29 have demonstrated that users of mindful practice activate different neural circuits in the brain. Mindful practice teaches students to develop an interoceptive awareness by pausing to focus on the body.22,26,2' In doing so, right brain structures promote self regulation with awareness of thoughts, feelings, and body sensations.29'31 The insula cortex, critical for self-assessment, feeds this information forward to the prefrontal cortex in what is described as a functional shift to the left brain or executive functioning centers.18,26,29,32'34This way, users of mindfulness learn to attend to their thoughts and the effect these have on the body so that they can act with awareness. In contrast, the default mode,2''29 characterized by midline neural circuitry, automaticity, and poor self-awareness, allows personal narrative, memory bias, and other stress reactions to dictate the outcome.18,27,30,34,35 To illustrate, a student who is about to enter a patient's room may pause intentionally to notice their thoughts (fondness/aversion) and the associated senses within their body (openness/tightness). …