Write a reflective paper in which you critically reflect on a patient care encounter that challenged your cultural assumptions as a PMHNP trainee.

Write a reflective paper in which you critically reflect on a patient care encounter that challenged your cultural assumptions as a PMHNP trainee.

the time. (Content)
o Discuss how it happened. How did you approach the situation? How did you perform? How
did the behaviors or choices of others impact you? What went well? What didnt? (Process)
o Consider why things happened as they did. What assumptions did you and others make?
What system factors may have contributed to this problem? (Premise)

STEP 3: OBJECTIVE
Reconsider the experience by obtaining
1) Other peoples perspectives: Use open-ended, open-minded questions (or tell the story in
S) to elicit opinions, interpretations and feedback from mentors, supervisors, other
professionals, patients, families, and/or peers, and/or
2) New data: Consult the medical literature or other sources of relevant information.
Useful objective data will reframe the experience, identify key issues, and deepen your learning.

STEP 4: ASSESSMENT
Synthesize your learning: What educational, personal or professional strengths and weaknesses
have you identified? How can you relate this experience to your past experiences to identify
important challenges? What personal/professional patterns have you identified? How has this
analysis affected how you will approach similar situations in the future? Look for larger learning/
professional development issues. Specify lessons learned or questions/learning issues identified.

STEP 5: PLAN
Make a plan to address future similar challenges. The plan should be SMART: Specific,
Measurable, Attainable, Relevant and Timely.
Include: a) what specific next steps you will take; b) where you can get the information or
help you need; c) who you will check in with and when; and d) how you and your check-in
person will know whether or not your plan is working. If the plan is SMART, you should be able
to assess the utility of your action items for furthering your learning or practice in days to weeks
or months at the most.
9.2011 Louise Aronson MD, MFA

LEAP FAQs

Will this really help me be a better health professional?
There is a wealth of theoretical data and a growing number of studies to suggest that it will. Specifically,
critical reflection promotes life-long learning, self-care, and professional development by helping trainees
and practitioners identify gaps in their abilities and knowledge and develop critical reasoning, problem-
solving and self-assessment skills. Recent studies suggest reflection improves test scores, decreases
diagnostic errors, helps trainees meet rotation goals, and improves professionalism. A reflective
professional is one who has an open mind, thinks about his or her own thinking, learns more deeply,
connects with his or her feelings, considers perspectives other than his/her own, strives to learn from
rather than deny or ignore errors, problems and learning gaps, and reframes his/her thinking to formulate
reasoned approaches to clinically uncertain and complex situations.

Why cant I just reflect however I want?
Analysis of hundreds of reflections by medical students and residents revealed that most consisted of
moving or disturbing anecdotes. While such experiences are ideal for reflection, the reflections
themselves showed little evidence of learning: identification of key issues with outside help, reframing of
the situation, integration of past and present experience, and specific plans for learning how to manage
similar future situations.

Why do I have to write the critical reflection?
Technically, a critical reflection does not have to be written. However, writing promotes critical thinking
and offers ongoing opportunities for feedback and accountability. Alone or with a mentor or colleague,
you can look back at your reflection to assess your professional development. Creation of a product also
shows commitment to learning and ownership of your experience. Finally, writing is a fundamental skill,
essential not only for scholarship but for professional communication via chart notes and consults.

Is there any way for me to know if Im critically reflecting well?
Weaker reflections: tell a story without analyzing it AND/OR consist largely of the reflectors opinion of
what happened AND/OR include only vague generalizations about what the reflector might do to
improve, i.e. I need to slow down and listen more to patients. In these reflections, the reflector usually
knew the outcome of the reflection when s/he started writing, so little was learned from the exercise.
Stronger reflections consider the reflectors thoughts, emotions, values, and assumptions AND include
input from others, even (especially) when that input differs from the reflectors own impressions AND
provide a clear articulation of a specific learning issue and a specific plan for approaching similar future
situations. In these reflections, the reflector often chooses the experience for one set of reasons and then
recognizes other key personal or situational issues critical to her/his professional performance after input
from others. Stronger reflections demonstrate courage by confronting real, unresolved challenges.

What can I do to improve my ability to critical reflect?
Like any skill (suturing, endoscopy, breaking bad news), some people will have more inherent aptitude
for critical reflection than others, but all will improve with practice and constructive feedback.

Here are some tips for better reflection:
Pick an experience in which you were a major actor or to which you had a strong reaction
Avoid excuses and whining and avoid self-congratulation
Dont make vague generalizations; specify thoughts, feelings, and objectives
Dont skip steps in the LEaP; each serves an essential role in creating a effective analysis
Work toward a different perspective, improved knowledge, new skills or attitudes
Remember the objective isnt beautiful writing, good storytelling or self-promotion but the
demonstration of purposeful thinking, critical analysis and professional development.

EXEMPLAR OF THE PAPER:

Treatment Planning for Trauma Related Conditions
LEAP Exemplar
Chief Complaint: psychotic delusions with an uncertain trauma history
Subjective: I was asked by my psychiatric supervisor to assess a 15 year-old client
with psychotic delusions for psychotropic medication management. However her
guardians and therapists were medication resistant, convinced that an unknown
past trauma was causing her to have psychotic symptoms. As such, they thought that
if the trauma were dealt with in therapy, then the psychosis would go away.
The thoughts in my head during the assessment conversation were 1) how can they
not see that she is overtly delusional and psychoticshe believes she is a queen, is
not human, and that her peers are her slaves, among others; 2) how much can we
bank clinical assessment on a past trauma that may or may not have happened (the
family suspects past abuse by a distant cousin, but the patient denies and the family
does not have any evidence it occurred other than the fact that the patient came
back sad from spending time with this cousins family); 3) how can I convince
them that both therapy and medications are needed at this point?
I performed fairly in the situation, although I did likely downplay the affect on the
potential trauma on the psychosis, so as to encourage them to consent to an
antipsychotic. I felt that if I gave them hope that therapy would heal her psychosis,
they would refuse to medicate her, despite her very acute state.
Although the family eventually consented to the medication, I found myself
unsatisfied with my sensitivity to their perspective in the interaction. I was pushing
my own agenda, rather than integrating what I know as best clinical practice into
the familys perspective on what will bring healing.
Objective: I sought out both my psychiatric supervisor for support in caring for this
patient. Having had a somewhat strong opposing reaction to the therapists and
families theory of causation, I asked this more experienced professional for advice. I
also consulted the medical literature to ascertain the relationship between trauma
and psychosis.
Here is the information I got from these sources:
In the literature, I found that early childhood trauma is a strong risk factor for
psychosis later in life, which I felt that I had known, but going back to the literature
reminded me of this correlation. What I did not find in my search, however, is
whether or not trauma focused therapy reduces psychotic symptoms. Or if trauma
focused therapy is even feasible in an acutely delusional or psychotic population.
During the consultation I made with my psychiatric supervisor, he stated that while
therapy will be extremely important in the treatment of this client, medications are
the priority to help her access therapy and to also calm down the fire of psychosis.
He said I was being hard on myself for not being sensitive enough to the familys
theory of causation, but that he understood that the conversation is difficult to have.
He also said that in his opinion, therapy at this point in time, would not necessarily
heal psychotic symptoms, but may help to prevent future episodes.
Assessment:
My professional strengths identified through this critical reflection are: an emphasis
on family-centered holistic care and a willingness to delve into medical literature to
ascertain whether or not a familys treatment wishes make clinical sense or not.
This strength will also create a challenge for me because my eagerness to provide
family centered care can make me question my in the moment clinical judgment
about how to treat a psychiatric symptom. By being too family centered, it may seem
that I do not have confidence in the clinical path I recommend. Balancing family
centered care as both a strength and a potential weakness will be important to
address on an ongoing basis.
This analysis has helped me realize how quickly and easily consultation can be made
to help guide important treatment decisions. Perhaps at the costs of quick clinical
decision-making, my thoroughness will hopefully lead to better care for this client in
the end. I would rather be based in best practice than look good doing something
without thoughtful consideration.
Plan:
The next time I come across a complex clinical case where I am unsure how to
balance best practice and family centered care, I will get the help I need by
consulting clinical literature and then discussing the case and the literature with my
psychiatric supervisor. He will be able to assess the utility of this action item by
asking how my comfort level with these types of patients is changing over time as I
practice these steps.
THANK YOU

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