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Reflective Theories

Kaitlin M. Brown

Occupational Therapy, University of Utah

OCTH: 6960 Advanced Topics

Dr. Price

September 7, 2021
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Introduction

Reflection is an essential aspect of occupational therapy practice as it supports a

practitioner's continual professional development (Laverdure, 2017). It also allows practitioners

to learn from their experiences and develop new perspectives achieved through reflective

practice (Atkins & Murphy, 1993; Gibbs, 1988; Kolb, 1984). This process helps to maintain

competence in practitioners (Mann et al., 2009). The skills required for reflective practice

include self-awareness, description, critical analysis, synthesis, and evaluation (Atkins &

Murphy, 1993). Different frameworks act as a guide to lead individuals through their experiences

and assist in developing the skills required for reflection (Moon, 2004). 

Reflective Practice Cycle

The reflective practice cycle is one framework that consists of six reflective stages. The

first stage is the description, or the facts, about the experience (Gibbs, 1988). I was working at

IMC inpatient with a man that had Guillain-Barre. At the time, he only had upper-body

movement with minimal strength. Previously, he told me that his biggest goal was to go to the

bathroom by himself because using a brief was degrading and he only had a ten-second warning

before urinating. The session focused on problem-solving placing and using a urinal within the

ten-second timeframe. The client was provided education on the placement of his urinal at his

bedside to ensure quick access. We also provided the client with snap-away pants and educated

him on leaving his brief undone on one side while in bed. The client refused to try all the

provided techniques and stated that he was thankful for our effort but was not ready yet.

The second stage of this framework is about the thoughts and feelings related to the

experience (Gibbs, 1988). During this session with the client, I felt confused and frustrated. My

CI and I had spent time brainstorming how we could help him use the urinal. We knew from his
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current functional status that he would be successful. I thought it was a lack of effort or

motivation and potentially a lack of confidence in his physical ability. 

The third stage of the framework is evaluation. This stage of the reflective practice cycle

focuses on the areas that went well and those that did not (Gibbs, 1988). One area that went well

was that I provided the client with client-centered interventions. He also recognized the effort

behind the strategies and that I was trying to target something that mattered to him. However, the

client did not participate in those strategies and did not progress towards his goal. I, as a

therapist, was unable to motivate the client to participate.

The fourth stage of this reflection process is the analysis and synthesis (Gibbs, 1988).

Looking back on the experience, I realize now that the client was very likely overwhelmed. I

knew he had anxiety related to therapy, and I knew that he felt like assistance with toileting was

degrading. I walked in ready to help him overcome his physical barriers, but I also asked a lot of

him psychosocially. I did not pause to ask him how he was feeling. I now realize that I did not

target or address the psychosocial barriers. I continued to provide strategies that required a level

of intimacy with which he was uncomfortable. I wrongly viewed that as a lack of effort and

motivation. 

The fifth and sixth stages of this cycle are the conclusion and action plan (Gibbs, 1988).

To conclude this experience, I should have stopped and addressed his psychosocial barriers and

had a conversation about what he was thinking and feeling. Maybe then we would have had

participation. Lastly, for the action plan, I would address a similar situation differently. I will

have a conversation with my client before tackling a sensitive issue to ensure that I have all the

facts, information, and barriers. I will slow down to the client’s pace and check in to ensure they

are comfortable. I will also think about the psychosocial factors before the treatment sessions. In
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the future, I will monitor my client’s comfortability through questions, and if I notice that my

client is not actively participating, I will stop and address the reasoning.  

A Reflection Process

The second available framework includes the what, so what, and now what phrases

(Rolfe et al., 2001). The first step of this framework consists of describing the event and the

thoughts and feelings involved (Rolfe et al., 2001). I was working with a woman at IMC that had

a stroke in the left hemisphere. Her right arm had no active movement, and she had global

aphasia. She also tended to refuse therapy and swat at hospital staff. I completed an ADL session

with her to address dressing. I first educated the client on how to remove her shirt. She was

attentive and nodded to acknowledge the steps. She completed the first step correctly, and I

praised and acknowledged her actions. However, as I provided the feedback, the client no longer

listened to further input and strategies for doffing or donning a shirt. She required moderate

assistance to complete the task. In this situation, I was confused by the client’s response. I was

there to provide methods, yet she ignored me after I provided praise. 

The next phase of this framework is the critical analysis (Rolfe et al., 2001). My

thoughts at the time were that she was independent and stubborn and therefore did not want help.

My knowledge at the time led me to think that due to her previous challenging behaviors and

independence, she was refusing my help and wanted to show that she was able to dress on her

own, despite needing assistance. However, now I realize it was my feedback that thwarted the

session and caused a negative reaction.

In the last phase, it looks at new perspectives and proposed actions (Rolfe et al., 2001).

Looking back at this experience, I realize that I was not using interpersonal reasoning. Upon

reflection, I realized that by providing praising feedback, I was impacting the client’s motivation
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and willingness to listen to the strategies I provided her. In future sessions, I will be more

mindful of this interpersonal reasoning. If I notice that a client has stopped participating, or their

participation has decreased after receiving praise or other forms of feedback, I will adjust my

therapeutic sense of self to fit the client’s needs more accurately. I will also ask the client what

type of feedback and support they prefer if I notice that their participation or perhaps my rapport

with them has decreased.

The Strands of Reflection

This final framework has four strands of reflection, including the factual, retrospective,

substratum, and connective strands (Fish, 1991). This experience also occurred at IMC inpatient.

I was scheduled to work with the client mentioned above, who had a left-sided stroke, global

aphasia, and had developed complex regional pain syndrome in her right upper extremity. Her

husband had approached me outside the door to inform me that the team had decided to

discharge her to a SNF and she would not accept therapy. I asked the client if I could help her get

dressed, and she agreed. I accidently touched the top of the client’s hand, which she perceived as

painful. The client stated that she was done. I offered treatment alternatives, which she refused. I

approached my CI to let her know the client was finished, but my CI wanted the full minutes and

asked that I continue. The client refused therapy five times in total, with me communicating to

my CI each time that she was done and my CI providing alternate treatment ideas to return to

the room with. In this moment, I felt stuck between my client and my CI. I was frustrated

because I was not able to make the decision to end therapy at that time.

For the retrospective strand, I felt like I was not respecting the client’s wishes and her

right to refuse treatment (Fish, 1991). However, I also felt concern in stating my thoughts to my

CI because she was my supervisor and I was a student. I realize now that part of my role as a
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therapist and student is to advocate for my clients and to follow the ethical standards. While I

told my CI that my client had refused, it was up to me to advocate for my client’s wishes and

needs. I do not know if I fully communicated the extent to which the client was refusing therapy

and what had all taken place. My inability to voice my reasoning played a role in the client

refusing therapy five times.

When looking at the situation now in the substratum strand, I realize that my supervisor

valued productivity standards and that motivated her to push for minutes (Fish, 1991). I also

came into the treatment with the belief that I should follow my CI’s lead because she is the

experienced professional. Due to these beliefs, I did not advocate for my client or her wishes

resulting in an ethical dilemma. My personal theory aligns with the AOTA Code of Ethics, that

the client has a right to refuse therapy (“AOTA”, 2020). One theory that would have been helpful

to utilize is the Person-Environment-Occupation Model (Law et al., 1996). This would have been

a positive theory to discuss with my CI, as the client and the environment were not congruent,

limiting the client’s participation. We were unable to achieve congruency in all three areas in

therapy and it was prohibiting her from participating in her occupation in a meaningful way. We

continued to push occupational tasks and participation, but without the congruence of the person

and the environment, the intervention may not have been beneficial. This would have been

important to share with my CI.

By reflecting on this experience in the connective strand, I learned that advocacy is a key

part in occupational therapy practice (Fish, 1991). Even on a small level of one client refusing

therapy, it is my responsibility to advocate for that client. Productivity is becoming a common

aspect of occupational therapy treatment and it can lead to non-occupation based interventions. It

is likely in future practice that I will have a supervisor, mentor, or manager above me and I have
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to share my opinion in an effective manner. I will also likely have productivity standards to meet.

In the future, I will communicate the needs of my clients in all situations and I will advocate and

respect their right to refuse therapy despite productivity. It might be helpful to write down bullet

points of the main points so that I do not lose track of what I want to say. I will also continue to

address my confidence and assertiveness both inside and outside of my practice. It may be

helpful to read books or watch videos on effective forms of communication.

Conclusion

Overall, reflecting on these experiences has allowed me to change perspectives and my

mindset on what occurred during these sessions. It made me aware of my shortcomings and how

I can better support myself and my clients. In the future, I will remember these experiences and

have a new perspective on how to handle similar situations.

References

AOTA 2020 occupational therapy code of ethics. (2020). American Journal of Occupational

Therapy, 74. https://doi.org/10.5014/ajot.2020.74s3006

Atkins, S., & Murphy, K. (1993). Reflection: A review of the literature. Journal of Advanced

Nursing, 18(8), 1188–1192. https://doi.org/10.1046/j.1365-2648.1993.18081188.x

Fish, D. (1991). Developing a theoretical framework. In D. Fish, S. Twinn & B. Purr (Eds.),

Promoting reflection: Improving the supervision of practice in health visiting and initial

teacher training (pp. 17-31). London: West London Institute of Higher Education.

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further

Education Unit, Oxford Polytechnic, Oxford.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and

development. London: Prentice Hall.

Laverdure, P. (2017). Using reflection to advance professional expertise. OT Practice, 8-11.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-

environment-occupation model: A transactive approach to occupational performance.

Canadian Journal of Occupational Therapy, 63, 9-23.

Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health

professions education: A systematic review. Advances in Health Sciences Education:

Theory and Practice, 14(4), 595–621. https://doi.org/10.1007/s10459-007-9090-2

Moon, J. A. (2004). A handbook of reflective and experiential learning: Theory and practice.

London: Routledge Farmer, Taylor and Francis group.

Rolfe, G., Freshwater, D., & Jasper, M. (2001). Critical reflection for nursing and the helping

professions: A user's guide. Basingstoke. Palgrave Macmillan.