Reflective Practice in Palliative Care
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Reflective practice is a way of being within the everyday clinical practice that makes us more mindful of the ways we think, feel, and respond to the situations. It is to look back at an experience, action, or an event with the intent of drawing insights to revise or better our practice. It also means pausing within a particular situation or experience to reframe the situation such that it makes sense and we proceed toward the desired outcome. However, for us to become better clinicians, we need to practice "reflection within the moment" which is a dynamic state of everyday practice where there is a constant interaction between the self (internal supervisor) and our past reflective experiences. Reflection within the moment is a conscious intent to realize a vision of practice that leads to "Mindful Practice." Mindful practice is the very essence of palliative care practice. Being mindful will help us to make the best judgments about situations by enabling us to look at the "bigger picture."
O’Donohue (1997) poetically states that "many people remain trapped at the one window, looking out every day at the same scene in the same way. Real growth is experienced when you draw back from that window, turn and walk around the inner tower of soul and see all the different windows that await your gaze. Through these windows, you can see new vistas of possibility, presence, and creativity. Complacency, habit and blindness often prevent us from feeling life. So much depends on the frame of the vision-the window through which we look." Clinical practice guidelines, protocols, and algorithms constitute knowledge. However, being mindful and mindful practice is wisdom, where you realize the vision to ease suffering and nurture growth through health-illness experience.
Understanding and acceptance of palliative care philosophy is the first and most important step to become a good reflective palliative care practitioner. Palliative care vastly differs from other specialties of medicine, which purely stands on the foundation of skills and knowledge. Conviction about principles of palliative care provides practical wisdom about the practice that sets us aside from the practitioners who base their practice purely on expertise. This practical understanding is essential for mindful practice.
Individual commitment is necessary for reflection. Commitment means the willingness to change, openness, curiosity, and intelligence. In palliative care, commitment is caring, where you are not defensive, but curious and ready to consider new possibilities. If we are committed, then every situation offers a unique learning experience that in turn helps in reflection and mindful practice. Reflective practice is always difficult to achieve in a busy world, and the practitioners who have become numb may not enjoy reflection. It is too painful to stand in front of the reflective mirror and face ourselves with the responsibility to care. However, incorporating reflective practice may help us to rekindle the commitment and reconnect with caring ideals.
Contradictions will exist in the initial phases of reflective practice where our age-old learned practice might contradict with the new way of reflective thinking. It could create stress among the practitioners who try to realize the vision of practice by mindful approach but contradicted by the beliefs, knowledge, or the learned behavior of self or their peers. Social norms, cultural expectations, authorities, peer pressure, and previous learning experiences are the critical barriers that could limit practitioner's ability to practice reflectively. These barriers could be overcome by rationalizing the basis for judgment and reconstructing and reorienting the people and the system to look at a situation in an alternate window (frame). It is not always an easy task, and there will be an inbuilt resistance for change, even by those who may benefit from the change.
At an individual level, reflective behavior needs developing our subjective inner voice that is continuously engaged in listening, valuing, evaluating other voices and views, and responding to a situation reflectively and mindfully. In addition to the subjective inner voice, we need to have a connected voice that can connect with the experiences of others through empathy and a dispassionate separate voice that can critique and reason. The construct of these voices, past reflective experiences, and practical wisdom from the understanding of palliative care philosophy will enable us to become mindful practitioners. In the early phase of reflective practice, it is always good to have a mentor. Mentoring provides an opportunity to debrief, vent feelings, solve ethical dilemmas, know best practice, and most importantly it will help us to understand the other person's view on the same issue. Junior doctors should always be provided guided reflection along with clinical supervision. It will provide a formal process of professional support, supervised learning, and an environment of trust and confidence and will create a culture that will enable them to be future mentors. The mentor should always listen, understand, clarify, guide, and empower his supervisee in the process of learning the reflective practice. It should be viewed as a quality assurance activity.
Reflective practice is essential and should be viewed as an important benchmark of good palliative care practice. Reflective practice tries to answer many human dilemmas of clinical practice faced by clinicians in their day-to-day practice. We now stand at the Crossroads of Medical Practice where one road is purely guided by studies, guidelines, and advanced technology with no consideration to deeper elements of humanities and the other road which is based on an intelligent application of knowledge, practical wisdom, and mindful practice. The last two lines of Robert Frost's poem "The Road Not Taken" states that "I took the one less travelled by, and that has made all the difference." It is our time to think and reflect on the right road that we need to pursue and pursue it with passion and purpose.