Reflective Practice in Audiology

Do you schedule 5 to 10 minutes between appointments to consider what went right or wrong during a patient encounter or how you related with the patient, as well as to jot down some notes that could prove helpful later? This article, based on the author’s lectures for the Ida Institute’s “The Process of Defining Hearing” seminar series, provides practical guidelines for fostering reflective practice in an audiological setting. It also introduces a helpful counseling tool called the Reflective Journal.

Christine DePlacido has been involved in audiology for 34 years and is a senior lecturer and program leader for the Audiology Department of Queen Margaret University, Edinburgh, UK, and a faculty member of the Ida Institute, Naerum, Denmark. During her tenure as an audiological scientist and head of service with the National Health Service (NHS), she trained in humanistic counseling, psychodynamic counseling, cognitive behavioral therapy, and hypnotherapy. She is presently completing a PhD in counseling, exploring the existential aspects of acquired hearing loss.

Reflective practice has been studied and implemented successfully in other health and caring professions to develop self-awareness and to enhance critical thinking and the ability to make judgements in complex and uncertain situations. When I began work in counseling, I realized that there were many techniques that could be borrowed from counseling that would help hearing care professionals (myself included) work more reflectively with patients.

Used consistently, reflection can help us to become more aware of the dynamic in the relationship between ourselves and our patients and other members of the patients’ world. Reflecting is not casually thinking back on the day’s activities; it is thinking about one’s own behavior in a deliberate, critical, and analytic way—pondering and considering one’s own actions.

Workdays of audiologists and hearing care professionals are often quite busy. Many of us have been practicing for a long time and have worked to improve our knowledge and skills on an ongoing basis. This dedication to providing the best possible counsel and care to our patients enables us to work with confidence in our abilities and our commitment. More often than not, “reflecting” is deemed necessary only when something goes wrong.

But reflecting—thinking about and learning from our own practice—can help us provide a better service for our patients. It can help us gain new perspectives on the challenges and issues we encounter in our practice. It can help us gain new insight into assumptions and responses we might otherwise take for granted. By reviewing how we interact with patients and looking for ways to make those interactions better, we can improve our judgment and prepare ourselves to take informed actions.

I have defined reflective practice as a means to explore issues in the patient-practitioner relationship and to process these issues in order to develop your ability to practice effectively. While reflective practice will mean different things to different people, I believe that, at its core, reflection is a way to look at relationships, to explore what happened in the interaction between patient and practitioner, and to reflect or think about how you can use that information to improve your relationship with your patient. It may mean that you change the way you practice or interact with patients or a particular patient. It may mean that you recognize that a person has an issue you can’t deal with and you need to send her on to an appropriate person who can help her. It might be there is something going on for you that is getting in the way of working with a patient that you need to deal with. Each encounter and each patient is unique, and different approaches work for different patients.

What Reflection Can and Cannot Do

A common misconception is that reflecting will stop complaints. In fact, complaints tend to be about people’s perceptions. Reflecting may reduce complaints but I don’t think it will stop complaints because you cannot take responsibility for the other person in the encounter. You can do everything that you feel you should do, you can reflect on what happened in the interaction, and you might think it went well. But the patient may walk out of the office and have a completely different perception. The interaction will be better only if patients perceive that the changes you make as a result of reflecting are changes that make the interaction better for them.

For this reason, a key question to ask ourselves as we reflect and come up with new ways to work with our patients is: “Is this what I think the person wants or is this what the person is telling me he wants?” If the interaction is taking a very long time and you still don’t seem to be getting the positive outcome you had hoped for, the question of what the person wants versus what you think he wants is a very valid point of view.

While it may not stop all complaints, reflecting can provide job satisfaction. As hearing care professionals, we don’t have the luxury of taking time to reflect between people. Our caseloads are such that we tend to finish with one patient and immediately move on to the next person in the waiting room. We don’t take the time to reflect—to let go of the first encounter before we move on to the second.

Move Higher by Scheduling Reflective Time

Is there anyone who hasn’t had a day in which one thing after another has gone wrong? You finish with one patient and meet with the next. While the second patient is talking, your head is still back in the previous encounter going over what went wrong. By the time you get to 5 o’clock, you’re completely frazzled and everything seems to have gotten worse as the day wore on.

It is quite different in a counseling setting where there are very strong boundaries to the interaction. Typically, a counselor meets with a patient for only 50 minutes of an hour. You don’t take the next patient until you have sat down and put the previous patient back into the place that they should be.

This sounds very prescriptive, but it is essential for the counselor’s professional perspective. In my role as a counselor, I work with many people who have addictions and who have horrific life stories. To go to another patient while I am still thinking about the person before would negatively impact my ability to work effectively with the next patient. The benefit of this built-in “reflecting time” is that, at the end of the day, you have off-loaded your concerns for each patient as you’ve moved from session to session. Not only is it a good thing to do for the effectiveness of your day-to-day work and the benefit to each patient, but reflecting develops you as a person.

Reflecting Basics

How do you reflect? First, you must make time to do it as soon after the encounter as possible. Make it a formal process—even if it is only 5 or 10 minutes—in which you sit down and quietly reflect on what has just happened. Reflective thinking is not a quick thought as you are putting away the patient’s charts or when you think to yourself, “Thank goodness that’s over.” Rather, you need to sit down and think about the encounter in a very focused manner. When you do this, the issues that are important to you from the encounter will rise to the surface and everything else will disappear. Think about the things that come up for you and that will help you identify what you need to work on.

Questions you should ask yourself: How do I really feel about the encounter? What happens when I am with that patient? Let yourself explore whatever comes up for you even if it is: “I never want to see her again.” If you don’t think at that level, it will be very difficult to get clarity on the encounter. Maybe it actually wasn’t about the encounter; perhaps the patient was rude or angry with you, or the patient was reacting to you over something that had nothing to do with what you did in the encounter. Use this information to look at yourself and to look at the patient.

As you exercise your reflecting abilities more often, you will find that you don’t always have to wait until the encounter ends to use these skills. The reflection becomes more immediate. You start picking up things as they happen.

For example, you might realize that in the course of a session, your relationship with the patient, which has been quite good, suddenly begins to change. Your patient is getting colder and more tense. There’s something going on in the room. You know you feel anxious and don’t know why. Because you have honed your reflecting skills to the degree that you are attuned to this change, you can say to the patient, “You know, just as we’re talking here, I’m starting to feel a bit anxious. What happened? Is there something we need to talk about?” You can actually address the issue at the time it arises.

Focusing on Feelings

Focusing is another technique from counseling that can be helpful in our work. Focusing helps you to use the biofeedback from your body to get in touch with your feelings. As you focus, you feel an actual physical shift in your body when you’ve got the right emotion. I encounter people in my counseling who have problems with behaviors, such as eating disorders. Often these people are not in touch with how they are feeling when they act out these behaviors. I encourage them to keep a diary and write down how they are feeling when they eat. What will come back to me in the first diary is usually something like “Ate bagels, feeling bored.” In reality, they are actually angry, upset, or frustrated, but they don’t want to get in touch with those feelings. They are completely detached.

In our professional life, we also tend to detach much of the time. I once had someone comment to me that “professionals should not have feelings.” It was one of the saddest things to hear. What she was saying was “I can’t take my feelings into that room with me.” Unfortunately, she has it wrong. To work effectively with your patients, whether you are counseling people on behavioral disorders or hearing loss, practitioners must engage wholeheartedly in the interaction. Leaving your feelings at the door is not an option.

Equally important in the interaction is what the other person in the room—your patient—is feeling. Patients bring many things into the encounter. You might think, “Well, he was in a really bad mood so that didn’t go well today.” But in reflective practice, you must also ask, “Why was he in a bad mood? Was he relating to me in a way that wasn’t appropriate? Did something happen on the way in?” As an example, the patient may have told your office manager repeatedly that, because he is partially sighted, he would prefer an appointment before 4 o’clock so he doesn’t have to travel home in the dark. But no one passed on the information to you, and when his appointment is again scheduled for later in the day despite his requests, he’s angry. It can be something as simple as this, but if you do not tune into his emotion and question it, you will not be able to regain the positive aspects of your relationship.

From Understanding to Action

It is critical that the reflective process take you from thinking about what you did to what you could have done differently to an actionable plan of how you will introduce this different technique or behavior into your practice. There is no point in reflective thinking if you don’t allow the knowledge you acquire to influence or change your interaction in future encounters or with future patients.

For example, when you are in the clinic room and start getting that same familiar feeling, you need to recognize what that feeling is telling you—such as “I don’t do well with aggressive people.” This kind of self-awareness can help you catch yourself and avoid the predictable and unproductive behavior.

Obstacles to Reflection

In the ideal scenario, reflection is used after each patient. What prevents us from reflecting? Often is it simply not making the time to do it. There is no point in reflecting on a session or a situation at the end of the day when you’ve seen six or more people, because the day’s experiences will be bundled together in your mind. It will be impossible to get back in touch with a specific encounter and learn from it. I recommend that you take even 2 minutes to jot down a few notes to yourself as you are starting to write up your journal or your case. You can return to those notes at the end of the day and reflect on your experience.

In my work at the university, I can always tell the students who do not complete their Reflective Journal entries throughout the course, but instead wait until the end of the 6-week placement. Their reflections are textbook: “I was aware … I was feeling annoyed…” You need to be taking notes as you go along. We invest a lot of time in our education and keeping up-to-date, but few of us sit back and consider, “Was it me? Was it something I did wrong?”

It can be even harder for someone to ask these questions as you are working with a patient. But if you are not willing to experience this type of introspection or self-criticism, it will be really difficult to reflect. We all know people who say, “I’m the expert, just do what I advise and you’ll be fine”—and who have no insight into how this attitude affects other people. Lack of self-awareness is the biggest obstacle to reflecting.

The Danger of Assumptions

On the surface, it appears easy to reflect, but there are many psychological processes going on beneath the surface that we are often unaware of. These processes come into the consultation room with us—and with our patients.

Although it may not be within the sphere of hearing care professionals’ responsibilities to address phenomena such as transference, counter transference, and ego defenses, having an understanding of these basic concepts and their impact on relationships will help to develop our ability to provide patient-centered care.

Transference occurs when a patient sees you as somebody else. Something you say or do reminds the patient of something or someone from his past. For example, you might remind a patient of his favorite grandson who looks after him. He will respond to you as he would to his grandson, doing all that you tell him to do because he loves you.

In transference, positive or negative aspects of the person’s relationships may come into play. For example, the patient who sees you as very much like his grandson may never have to call his grandson in advance to say he’s stopping by because he is always welcome. What happens when this patient arrives at your office without an appointment? When you explain that you are very busy and ask him to wait while you attend to your next appointment, the patient is hurt and angry. You have broken the image he has of you as the loving grandson.

Counter transference can be even more dangerous when the practitioner transfers her feelings or perceptions toward another person onto the patient. A patient may remind you of your grandmother who is a lovely person but not very technically minded and somewhat forgetful. So unconsciously, you begin to give information in a way that you think will be useful to your grandmother. The patient, in fact, may be a sound engineer who has a very good memory. But you have already made a decision on an unconscious level about who she is and a judgment about what she can handle.

It is critical that you are aware of how you relate to a patient and that is something that you need to consider as you reflect. Reflection is not only about what went well or wrong, but also about understanding your relationship or way of relating to the patient.

Stereotyping leads to assumptions being made about patients, often before you have ever seen or spoken with them. It can be more insidious than transference. You have all seen referral letters from doctors that begin “She is a delightful old lady … she seems to be hard of hearing … she seems to be struggling today, can you see her?” You go into the waiting room looking for a lovely lady who is going to be all smiles. When the “delightful old lady” starts to act differently than your expectations, you wonder what is going on.

I was a patient in a hospital years ago, and after I was discharged, I went to see my family doctor. He told me that while I was in the hospital, I had been characterized as “the patient from hell.” Why? Because I kept asking questions. At the time, I was completing my master’s degree and had an assignment on medical imaging. So as I had the various scans, I would ask, “Why do you do that?,” “How long will it take?,” “What does it do?” The assumption in the hospital was that I was being difficult. As with all encounters, this one was colored by opinion and perspective. Really understanding what was behind my questions, rather than assuming I was “the patient from hell,” would have changed the experience for all of us.

If I could have my way, I would have everyone read the referral after they had first seen the patient. In fact, I don’t read referrals at all. I advise students not to take what they read in a referral letter as gospel. Put it to one side and ask the person questions. If you want to know how a person feels, ask her.

Ego defenses protect our psyches. Throughout our lives, we deal with many things that can be difficult. To shield ourselves from these difficult situations, we put defenses in place and use them every day. Everyone does. A favorite ego defense that I use is “acting out.” I am actually quite a technical person, and I’m not very frail so I can lift quite heavy things. But when a man comes into the room, I’ll often say, “Can you lift this for me?” because it gets the job done without any effort. I can go and have a coffee, and the person who helps me gets to be the man and do the heavy lifting and it all works fine. But ego defenses become a problem when people react with them at inappropriate times. For example, if someone has an aggressive boss, but they can’t express anger, they repress their frustration and anger at work but then may go home and kick the cat.

We need to get beyond our ego defenses when we are working with patients. We always talk about ego defenses in patients, such as people in denial who refuse to acknowledge painful realities, or people who regress and begin to act like children. But I don’t believe that, as audiologists and dispensing professionals, we are trained to be attuned to our own ego defenses. We tend to respond with “It’s not my fault that he can’t hear; I gave him the right hearing aid.” That kind of response stops when you look at the situation more closely, when you reflect on what else is going on in the encounter.

We also tend to rationalize situations. “I did everything right; I did the best I could do. This is not my problem.” This kind of response is not just denial; it is also rationalizing our behavior. “I can’t go home with the patient. I can only do what I can do in the office.” So many times we walk out asking what else we could possibly do, assuming that we’ve done everything we can. But even these frustrating situations should not stop us from reflecting on what happened. If, on reflection, you discover that ego defenses are interfering with your ability to counsel effectively, you may wish to consider counseling to help you break down those defenses.

Gaining Self-Awareness

Practice developing self-awareness. As you become more aware in the actual encounter with the patient, the counseling process becomes dynamic. You can see by the patient’s face that you’ve lost him. Or you realize that the older lady coming to the appointment with her daughter has completely disconnected from the conversation because you are focused on trying to get information across to the daughter. You have made the assumption that the mother isn’t going to understand. You might think that you’ll explain to the daughter before they go home so she can help her mother. But what has happened at some point is that you have become totally oblivious to the fact that the mother was trying to get into the discussion.

If you are aware of what you are doing, you will be able to stop yourself, and say to the mother, “You’ll also want to see this” or “You’re not in a good position to see this. Let me move around so you can see better.” Her response will be a sense of relief and validation. She will think, “Good, she understands me. I’m being listened to.”

Active listening is an important skill. I have interviewed many people for my PhD thesis, and they often say, “I see they [the audiologists] are listening to me but they are not hearing me. I can see from their faces they’re already deciding what I need while I’m still telling them what I want.” Sometimes you can recognize this phenomenon when you watch other people but you don’t see it in yourself. For example, you are listening to a patient but you are already thinking to yourself, “That’s a 30 dB loss. I think this hearing aid would be quite good.” And your patient suddenly thinks, “She’s not listening.” It is so easy to do.

If you are practicing self-awareness, a person can be talking for 20 minutes and, if you’re really listening to them, they’ll say something and you’ll get a reaction in your body. You’ll say, “Oh, wait a minute, that was important. I’m getting engaged. What was that about?”

The Most Important Tool

You are the most important tool you can take into the consulting room. Nothing can be as good or as beneficial to the patient as what you do with yourself in the encounter.

Don’t leave your feelings at the door. It’s distressing when you are with someone and you don’t connect with them. How can you work with them? I am not suggesting that when a patient starts to cry because he’s lost his hearing, you start to cry with him—although that can happen. You must at least be able to acknowledge the fact that the patient is upset. If a patient shares something and it is upsetting, what should you say to her? Perhaps something like, “When you tell me this, it’s quite upsetting to you so obviously it is very important to you. Can we talk about that?”

Really listening to and hearing the patient helps you to make the encounter more informational and more personal. It begins to build a relationship. Reflective practice and the self-awareness it fosters will help ensure that you are truly engaged in each patient encounter. For many of us in hearing health care, it is a new way of thinking and working. The rewards of your enhanced ability to deliver true patient-centered care—for you and for your patients—are well worth the time and energy you invest.

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Correspondence can be addressed to HR or Christine DePlacido at . For more information on the Ida Institute seminar series, visit www.idainstitute.com.