In the children’s clinic – a mother arrived with her 6-week old baby looking very anxious. 

Before she had even sat down, she asked what would happen and if it was going to hurt her son, as she’d had been sent by her midwife, and really didn’t understand what to expect. I asked her to take a seat and said I would explain how the session would run. As she was so anxious, I decided to ask her if I could touch her wrist to demonstrate the levels of pressure we apply to babies during treatment. She immediately appeared calmer and less worried, and I was able to explain how the session would run and that she was in control at all times and could decide to have no treatment for her baby, or stop at any time. I explained that we work with how the baby responds and breaks could be taken for cuddles and feed as she wanted. 

The mother had valid concerns that needed to be addressed as soon as possible to ensure she was involved in decision-making and consent-giving for the assessment and treatment of her baby. Whilst we are familiar with how babies are treated in the clinic we must remember our parents may not be. I felt confident in my ability to reassure her and was able to communicate in a way that instilled confidence. I felt showing her the pressure on her own wrist was a very useful nonverbal tool to reassure her. 

During the treatment, I checked in with the mother to if she was still happy to continue treatment and made a particular effort to explain what I was going to do, how it would be done, and what I was feeling. I explained the changes that I felt in the baby’s body during treatment. With one technique baby did not appear to like it so I stopped, I would do this with any baby, but it was important to demonstrate this overtly for this mother. 

I felt I was able to contain the concerns of the mother by remaining calm and immediately identifying that she was worried it would hurt her baby. Demonstrating the pressure was hugely reassuring, without doing that I think she would have remained anxious, and this may have affected the rest of the session. I was able to start from where the patient’s mother was at. 

I was able to remain calm, and this demonstrated to the mother that I was confident in what I was doing. 

This was my first overtly anxious mother, and I had not demonstrated the pressure on another parent before, so it was a spontaneous decision and one that I will use again.  

The mother and baby are still a unit in the fourth trimester, and the mother’s well-being is as important as the child’s. Labrie et al (2020 ) found that parent-provider communication is a crucial determinant for parental well-being and satisfaction with care, during and following infant hospitalization in the NICU. Whilst children’s clinic is not as stressful for most as NICU, it should not be underestimated that it can be a worrying time. 

·         I will continue to remain mindful of where the parents of young babies are at in terms of anxiety and concerns.

·         Post natal mothers are potentially vulnerable emotionally and how we communicate is so important especially when it relates to their most precious babies. This will be particularly important where a referral for an medical investigation is required, which I have not yet had the experience of questions being asked.

·         It is really important to offer the opportunity to ask questions in a way that invites  

References

Labrie, H.M.N., van Veenendaal,N. R., Ludolph,A.,  Johannes C.F., Ket, S. R.D., van der Schoor, A.A.M.W. van Kempen. 2021. Effects of parent-provider communication during infant hospitalization in the NICU on parents: A systematic review with meta-synthesis and narrative synthesis, Patient Education and Counseling,Volume 104, Issue 7. Pp1526-1552,

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

A patient attended the clinic with his wife, and I was asked to see him as a cover patient. The notes stated he had dementia. I introduced myself and explained that I was covering for another student. 

Drawing on my previous career I took great care in addressing the patient directly asking him how he had been feeling since the last treatment and if he had any questions before we started the examination. Only when he had finished speaking did I look to his wife to check if there was anything else to add. Due to his dementia and concentration concerns, I would use his name a lot to ensure that he was focused before I started to explain things to him. I asked at each stage whether he had any questions. I spoke in short sentences giving full eye contact to ensure he knew I was listening and to ascertain if I thought he was understanding what was being said. this obviously took longer but it was very important to ensure he understood. It would have been quicker and possibly easier to speak to his wife, but this was uncomfortable for me and did not work within a person-centered approach. 

In fact, the patient’s wife modelled this herself by not speaking unless asked directly, and on one occasion when I asked the patient a question but looked at her (hopefully the only time I did that) she looked to her husband to answer. A subtle but strong reminder of putting the patient with dementia first. 

Having a patient-centered approach enables the development of a working relationship, even within the realms of dementia. It shows respect (which is why I was embarrassed to have my slip picked up by the patients’ wife, no matter how politely she did this ).  

I have experience of working with people with dementia from my previous career, so thought in many ways I was the ideal student to work with this patient. However, as mentioned the patient’s wife highlighted an occasion whereby I did not communicate as effectively as I had thought I “naturally “ would. This was uncomfortable at the time and more so on reflection. However, it was useful and thought-provoking because it allowed me to think about how I communicate. I generally think I do this very well but clearly, on this occasion I didn’t. It also highlighted the strength of the patients wife who was clearly alert to this and not afraid to subtly highlight this . Another positive is that I picked up on the unspoken cue and adapted immediately. 

Communication as an osteopath is as important as the diagnosis and treatment, without it there is the real possibility of information being missed. It should be considered the glue that holds the framework of person centred care together( Lin et al 2019 )

·         I need to always think about how I communicate with patients, and not assume “ I know how to do it “

·         Remain alert to how my patient wishes to communicate

·         Be mindful that assumptions can lead to a power differential and this does not work within the patient-practitioner model of shared decision making. 

References 

Lin,I., Wiles L., Waller,L., Caneiro,R.,Nagree,JP., Straker,Y., Maher,L., O’Sullivan, C.G., &Peter,P.B. 2019.  Patient-centred care: the cornerstone for high-value musculoskeletal pain management. British Journal of Sports Medicine. 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

Second entry 

OPS A2

During lockdown we had online tutorials where the clinic tutors. During  this time I worked really hard to work on ways to communicate diagnosis and conditions to the tutor he was role playing the patient. Whilst I feel I have good communication skills this was sometimes a challenge when describing medical or physiological conditions in layman's terms that didn't diminish the importance of what needed to be said but needed to be communicated in a way that was understood. I found this experience extremely useful and I implemented as far as I could the skills in clinic with my real life patients.

New patient script 

Hello and welcome to the ESO student clinic and thank you for coming in to see us. 

My name is **** and I will be your student osteopath today. 

Just to let you know, as this is teaching clinic , my tutor may be popping in and out throughout the appointment today if that’s ok.  If at any point you have any questions or concerns, do ask. 

Have you seen an Osteopath before?  I will run through the whole process here at the ESO with you before we begin, just to give you an idea of what to expect and the procedure that we follow.

To begin with, we will discuss the reasons you’ve come in today. In order to get a more complete picture of your case, we will discuss your medical history, including your family medical history.’

I will then leave the room to discuss my diagnosis with my tutor, which may take up to 15/ 20 minutes. After which I’ll explain what we think is going on with you.

The aim for today is to get a detailed picture of what brings you in today,  and to establish whether or not osteopathy is the right treatment for you today, or if another profession would be better option . You also have the choice to not have treatment and have a think about whether you want to have osteopathic treatment, in which case we can rebook.  

Do you have any questions? 

 Examination process . 

I may ask you to remove some items of clothing, but its not obligatory  but does allow me to see  your joints, skin and movement better . its important that your feel comfortable . 

If you would like a chaperone during this process, please say and it can be arranged. Also, if you would like a gown, please just ask. 

During the examination I’m going to get you to do some movements and tests. Some of these tests could be uncomfortable, but this will help us in the diagnostic process. This means that you may be feeling a little achy and tired when you leave today, and this can last for up to 48 hours.  This is not uncommon, but this causes  you problems with your plans today we can rebook. 

If at any point during the appointment, you feel uncomfortable, or am not sure about something, please just say.

Do you have any questions or concerns? And are you happy to proceed? 

I wrote this consent speech early in year three to help me prepare and I thought I covered all aspects with all patients especially new ones. However as I go nearer towards the CCA exams I'm asking for tutors to be more present to enable really clear feedback, it's become apparent that I don't always do this. It is easy for us as students who are used to the process, possibly comfortable now with being seen in limited clothing to feel comfortable with the process. It's imperative that we do not forget patient modesty, comfort, safety and consent. It is not simply a case we may receive a complaint, which obviously we want to avoid, it is about treating people with dignity, and allowing and ensuring they make decisions based on the best information possible at all times

·         I will strive to ensure this I never forget the basics of consent to treatment dignity and respect for my patients. 

·         I understand that poor communication is the primary cause of complaints to GOsC. Whilst I want to avoid a complaint, my primary concern relating to this section is that I communicate well with my patients to develop a good working relationship, that is free from misunderstanding.

·         Whilst I consider myself a good communicator, I can’t take this for granted and I need to be mindful of this at all times, and adapt as required. 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

A cover patient in the general clinic - I was asked to cover a patient at short notice, so I had limited time to read the notes in detail but did read the patient had dementia. The patient presented with his wife, and I ensured I directed my conversation towards the patient and not his wife. The patient then rebooked with me the following week, whilst reading the notes I could see there was no reference to his capacity to consent to treatment, or his wife’s legal responsibility. I bought this knowledge from my previous career in social work. 

Before proceeding with treatment on the second session, I asked his wife whether she had Lasting Power of Attorney, which she replied she did for both care and finances. I discussed this with my tutor who appeared surprised by me raising this issue, and did not seem unduly concerned that no one had checked the legal position of him having the capacity to agree to treatment. 

I felt that the tutors who have been involved in this case prior to me becoming the patient’s practitioner should have picked up on the issue of capacity to consent to treatment, I'm of the view it is remiss this had not been done.  This potentially leaves the tutors as well as the clinic vulnerable to a complaint or worse. On further reflection whilst I added the Lasting Power of Attorney information to the front sheet of the file, I didn't ask for proof of this legality. I feel I should have asked the patient’s wife for this. 

Another area of reflection I had whilst treating, is the type of treatment that the patient’s wife was consenting to. Whilst the patient wasn't a candidate for cervical manipulation it did raise the question about whether I would do a cervical manipulation on a patient he wasn't consenting themself. I think on balance that no osteopathic technique is so crucial, that I would proceed without the patient themselves consenting, especially given the potential risks for a cervical wheel for example. this is something I'm going to continue reflecting on this in relation to this and other Osteopathic techniques that require very detailed consent. However, the Lasting Power of Attorney does allow the patient’s wife to make decisions on his health and welfare. (internet 1 ) 

I advised the clinic manager of the situation. The clinic should have better safeguards in place for these situations. 

·         I will strive to treat cover patients as if they were my own patients and ensure I have all the info I need before the session. 

·         I will ensure that all the legal aspects are collated and documented prior to treatment, to protect both myself and my patients.

·         I won’t assume that checks have been made.

·         I will continue to alert the clinic manager of any issues that I may encounter, so that these may be addressed and rectified. 

·         I continue to reflect on the issues around this case as the omissions were potentially serious. 

Internet 1

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan.

A4. “You must receive valid consent for all aspects of examination and treatment and record this as appropriate.”

In my final CEX exam in 4^th year (see CEX above) I had a patient with a complex presentation. 

I have worked hard throughout my time in clinic on obtaining valid consent, and this was reflected in the mark I was given in the CEX. 

·         I will ensure I continue to obtain valid consent in my future career

·         I will remain vigilant to share decision making with patients.

Reference

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

 

A morbidly overweight cover patient in general clinic – 

A female patient attended clinic as I was asked to cover. I was aware the patient as my colleague had discussed her and the frustrations she felt about her non engagement in homecare/ exercise prescription. The patient had been seen in the clinic over a number of years. 

The patient is morbidly obese, with addition health issues, reduced mobility due to pain. She had two previous surgeries for gastric sleeves that had not worked. She found exercise difficult after about 5 minutes of walking and was not motivated to exercise. 

Reading the notes I saw the homecare/exercise that was set and I felt this was beyond the patient’s capability at this time. She was struggling to maintain her weight let alone lose weight. I was unclear what benefit she gained from her 6 weekly osteopathy, other than very minor and temporary pain relief, which she appeared happy with. 

My colleague was frustrated as she couldn’t understand why the patient would not exercise to address her weight. I decided to take a different approach to see if she would engage with additional movement, reframing it from exercise which I wondered if she mentally and physically could not do. I asked how far she could walk and she said 5 minutes. I suggested a 5 minute walk alternate days for a week, building up to everyday and then add an extra 30 seconds of walking hoping this was not too challenging but noting it is probably more than she does now. I suggested dancing to music and gentle mobilisation. 

The tutor was challenging why we continued to see her in the clinic if she was not going to comply with the prescribed plan and said we should discharge her. He also said that I should not over-invest in her as she was unlikely to change. 

I reflected on this, firstly my colleague was young and very fit and I wondered if this was why she got frustrated with the patient’s lack of investment in exercise. The tutor felt we may be taking financial advantage of the patient by continuing to see her and that I could overinvest in her. I concluded-

·         The patient feels she gets temporary relief from pain which she is pleased about 

·         She books in every 6-8 weeks of her own choice, so one could argue the patient has autonomy in her care.

·         This timescale means a degree of distance so over investment with her as well as being mindful to it is not likely a problem

·         The patient is limited to what she can do physically by virtue of her current size, therefore as a practitioner, I have to start from where she is at, rather than imposing on her what I think she “should” do. 

·         Her ability to lose weight is limited with out surgical intervention  REF

·         However, the surgeries she has had have not been successful.

·         There are psychosocial factors that have not been identified. 

·         Whilst I understood what the tutor was saying about not over-investing in the patient, and that I feel I am already quite boundaried. 

·         I felt that the was an undertone of negative feelings towards the patient from the tutor. Studies have shown that obese individuals hesitate to undergo necessary examination and screening procedures due to expected stigmatisation. (Sikorski et al 2013 ) , thus this becomes a self-fulfilling prophecy.  I feel we have to try and understand the patient’s perspective and their self-view/ worth, in order to support them. 

·         It is important to understand where the patient is at, and I will strive to keep this at the forefront of my interventions.

·         It is important that we try our best to understand the limitations of our patients and work with these. I will try to remember this and remain realistic in my expectations. 

·         Overweight people suffered from stigma in society and whilst I understand that this does impact health and places demands on health care services, I will always strive to create a safe, welcoming, and supportive space to allow the maximum effect of the therapeutic benefits of osteopathy. 

 

References 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

Sikorsjki,C., Luppa,M., Glaesmer,H., Brahler,E., Konig, H.H., & Reidel-Heller,S.G. 2013. Attitude's of Healthcare Professionals Towards Female Obese Patients. Karger. Pp512-522. 

Cover patient – a female patient that I had not see before. I had asked the tutor to observe my session in preparation for the CCA exam. I left the room to allow her to undress, on entering the room again I asked if she would be able to remove her trousers. The patient said she would normally keep them on, I replied that was fine to do the examination with them on. 

The tutor fed back that I had not managed the issue of dignity well with this patient. I was mortified that I could have made a patient feel uncomfortable. 

On reflection, I realised that I had not noted what she had been wearing as I left the room, and thought she may have not understood what I had said. 

 So what 

I was disappointed that I had been clumsy in managing this situation, but glad to have had the feedback from the tutor. Although this patient was on the surface ok with being asked if she would remove her leggings, she may have been embarrassed, or worse felt pressured to get changed. 

It may highlight how normal undressing is for me as an osteopathy student, but I neglected to consider the patient’s perspective, which I pride myself on doing normally. 

·         I will endeavour to make sure this situation does not happen again.

·         I will make sure I communicate more clearly on this matter.    

References 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

This definition links clearly with the five osteopathic models in particular the biopsychosocial model, as osteopathy looks at the person as a whole, whilst trying to improve the overall health. 

No one treatment is the same and no one patient is the same, similar treatment will be perceived by different patients in a different way. This includes a physiological response to treatment, emotional response, and some may argue a spiritual response. 

Culture and beliefs shape the patient, and language may create challenges that the osteopath must embrace to understand the patient fully in order to treat effectively, and equitably. As osteopaths we must understand that if we do not strive to understand our patients we may deny them access to healthcare. We must strive to avoid discrimination on any level, osteopathy should embrace all people in all states of health with fear of negative attitudes or bias.

References 

World Health Organisation, 2006. Constitution of World Health Organisation, Basic Documents , Forty-fifth edition, Supplement.

Whilst  I feel I am naturally a very reflective person, I still feel it is vital to get feedback from colleagues and tutors to further improve on our practice. This will allow for unconscious incompetence to be managed. I always ask for feedback from tutors especially for areas for improvement. 

In my mock CCA in February 2022 I was given feedback “be sure to really listen to response to one question before moving to the next “. This came as a surprise to me as I feel that one of my strengths is active listening, something my previous career relied on.  I took this away and gave it thought. I realised that sometimes when I am in clinic and a patient is delivery complex information relating to conditions and in particular medication. I am trying to recall what these mean or how to spell them and this distracts me. I feel I can manage lots of information at the same time where it is either more straightforward or within my comfort zone. 

Now what. 

In relation to the mock CCA feedback, I have spent time revising my pharmacology and conditions to ensure that I am not distracted from the patients’ story and give my full attention. If I need to write whilst they are talking, I explain that I a listening and I will stop the conversation to allow time for the note taking which is necessary. 

I have also gone back to read Carl Rogers who developed Humanistic psychology which founded person-centered practice. This led to the reflection that although whilst I consider myself to have strong communication skills, This is something that I must continue to work on. whilst surprised at the comment made in the CCA I am grateful for the opportunity to consider and reflect on my communication skills. 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

Cover patient in first term of 4^th year- a 38 year old patient arrived at clinic with her 15 month old son, during the course of the discussion and treatment for her back complaint, she told me she had diastasis recti  as well as issues with her pelvic floor. This is something she hadn't discussed with the original practitioner.  Although I've had some training elsewhere to assess diastasis recti, this wasn't her presenting complaint that day. I also felt it was somewhat out of my scope of practice within the ESO clinic, therefore I felt it appropriate to give advice on alternative services. I discussed the Women's Health clinic at the ESO with her and explained the focus of that clinic. I also provided information on the Mummy MOT which is a programme that physios and osteopaths can train in which develops specific skills for the assessment and treatment of postnatal women. I felt this would ensure the patient receives the best care possible, which currently I am unable to provide due to the point within my training. 

I was able to recognise my limitations, and constraints of current training and refer on.

I did not feel fully confident in the full assessment of her pelvic floor (this wasn’t her primary complaint this session so I did not feel I was failing my patient, luckily.) I was waiting to start a women’s health clinic at this point. I reflected after that I had felt “lucky” that the patient had not wanted to address her pelvic floor issues and this actually highlighted a lack in my anatomical knowledge and was a significant gap in my knowledge. 

 I advised the patient that a woman is post natal for as long as she has issues relating to her birth. The patient was unaware of this, and that such services existed.  I also explained that as osteopaths we take the whole person and body into consideration and do not see individual complaints in isolation.  

·         I will work on my anatomical knowledge of the pelvic floor. 

·         I will practice the techniques to ensure that my skills reflect the needs of the patients that attend clinic.

·         I will seek advice from my clinic tutors to support my learning and hand on skills. 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

 

Feedback from examiner from a poster presentation of Sub Acromion Impingement Syndrome. 

“excellent use of models various included. Osteopathic and WHO . presentation of models not comparison. are we all following the same criteria in the end? Considered needs of individuals to what treatment type needed and what other modalities could be included “. 

I generally don't like public speaking so I tend to practise a lot beforehand I'm actually I realise but when I'm speaking I come across reasonably well I don't worry about small mistakes. I had my script to hand in large print which gave me a safety net, this calms my nerves. 

I had looked really closely at the marking criteria and what level 7 marking required. I worked really hard to integrate each osteopathic model in relation to the condition. I could have discussed more of a multidisciplinary approach.  

However I realised after the presentation that I could have done comparison of the models and this was confirmed in my feedback. However I was very happy with the feedback and the grade. I think my grade reflected my attention to detail in relation to research papers and consulting the marking criteria. 

This was one of the most useful projects we've been set throughout the course for me. It made me focus deeply on this condition, but more importantly the application of osteopathic models when I care for my patients.

This assignment really made me focus on the osteopathic models even more than I feel that I do and the importance of applying the models in real life in clinic. 

I will continue to consider the contribution that other professionals can provide. 

Gibbs,G., 1988. Learning from doing: a guide to teaching and learning methods. Oxford. Oxford Polytechnic. 

Gibbs,G., 1988. Learning from doing: a guide to teaching and learning methods. Oxford. Oxford Polytechnic. 

I consider myself to be a naturally reflective person, this stems from my previous career as well as I feel my personality type. I've always felt it's important to receive feedback openly, without becoming defensive, to enable the full reflection to take place. Whilst I feel I have certain strengths i.e. communication this has on a couple of occasions been picked up on in terms of ways I could improve how I communicate with my patients. As mentioned in B1 although initially I was a little surprised I did reflect and replay the conversations I had with my patient, to consider how they came across to the third person. I have I have worked hard to develop my communication skills. It's important that even though my previous career was based on communication that I am open to feedback, suggestion and constructive criticism. This padlet assignment has made me reflect in a more structured way using the models of Gibbs and Rolfe, which has provided some structure to something that I do instinctively. it is important open to feedback, and continue to develop my interpersonal skills. 

References

Gibbs,G., 1988. Learning from doing: a guide to teaching and learning methods. Oxford. Oxford Polytechnic. 

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

Initially for the first term or two in clinic this provided a really useful structure to ensure that all questions and relevant information were obtained. However moving into term 3 tutors started to suggest we move away from this format to ask questions in a more fluid and organic way. initially it felt a little unsettling not having that framework but I quickly realised that my interview with my patience were much more free flowing, natural and helped develop a better rapport. 

I continue to keep it in the back of my mind to share that nothing is missed in the case history taking.

I will use Rolfe et al (2001)  to reflect. 

I was feeling particularly nervous about this CEX as it was my first and I was also out of slot with a tutor that I didn't know. I felt on the whole the session went well but I didn't feel at all relaxed I think this affected my performance on the day. patient had asked if they should see a GP about their pain, I entered a conversation about why they thought of GP was a better option I listened and informed them I felt they were in the right place, and the osteopathic treatment could be very beneficial. 

I felt comfortable with allowing the patient to explore the possibility of a GP path rather then osteopathy, but the discussed in the feed back that I lacked authority. I discussed this in feedback and explained my approach to listening to patients To gather an understanding of how they feel before responding. I felt in this situation that being “authoritarian“ would have resulted in me not listening to my patient. I felt this demonstrated a different approach between myself and the tutor. 

I have reflected on what the tutor said and have given consideration to this. I think impart this may have been due to the lack of confidence being in 3rd year and with a tutor I hadn't met before. I have worked on my outward appearance of authority even when I have felt uncertain and will continue to do so. this is particularly important to develop a sense of confidence for the patient.

References

Rolfe,G., Freshwater D., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan.

In my previous career I would carry out assessments not dissimilar to the case histories that we do in clinic. My case history taking has always been one of my strengths on this course and hasn't felt particularly challenging to me. this being reflected in feedback that I have received from my clinic tutors. However one of the challenges has been to document clinical findings during testing etc in a clear and coherent way. This became apparent on a number of occasions when tutors were asking for detailed back on testing and clinical findings, and I was unable to quickly or coherently answer the questions. 

This made me realise I'm reflection that whilst in the moment those notes may make sense, that a week or two later or on cross examination, I was unable to understand clearly what I had written or what my findings were. this may be down to the pressure of time in clinic , and trying to get through your examinations as quickly as possible, nevertheless it's very important that the clinical findings make sense not only to me, but also to anyone else that has access to those files. this is particularly relevant in the  student clinic where we frequently have cover patients. 

·         I have worked hard to show my notes are clear and concise , and professional.

·         I will continue to develop in this area.

Rolfe,G., Freshwater D., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

Ability to use previous MH social work experience in clinic.

A new patient presented in the clinic, as I met him in the reception I realised the patient had some mental health difficulties. This became apparent when I came to the section of the history taking but asked about his alcohol consumption. he replied that he no longer had issues that alcohol since he's been in hospital for detox. I carefully explored whether this was as a voluntary patient or not, and he informed me he was on a section of the Mental Health Act (S37/41). my previous experience meant that I understood the implications of this section, i.e. a potentially serious crime with a restriction on the section being removed(S41) , unless agreed by the home secretary. careful explored medication I know and he informed me he was on the depot injection. The patient presented as slightly anxious, possibly suspicious, but no overt signs of paranoia. However, when I explain the process of examination, he said he would not remove his clothing. Again given my experience I observed his baggy clothing keeping in mind he may have weapons on him to protect himself. I was alone in the room at this time.

I left the room to speak to my tutor, and explain the situation, I also explained my very long social work career and understanding of mental health. The tutor said he would come into the room both I examined. I asked the patient if there was anything sharp in his pockets as I would need to move his hip to assess his pain, I'm not I didn't want him to get hurt, he said there was nothing in his pockets. He agreed to treatment, which was challenging given him wearing baggy clothes with thick jeans, and I needed to continue to watch his facial expression for any signs of hallucination. I said home care which was to walk for 20 minutes a day, which the patient said it would be challenging he felt very paranoid out of his house. 

I emailed the clinic manager immediately I said I need to discuss the safety of other staff members and student osteopaths, as I felt it was only because I understood mental health and had an in depth understanding of the Mental Health Act , that I understood what this gentleman was saying. I needed to explain to the clinic managers what the implications of section 37/41 are. It was agreed I would write on his notes and that's he should have a chaperone for both parties safety, in case of incidents towards myself, or accusations made against me, given his paranoia. 

 

On the 2nd appointment a male student from the year above agreed to chaperone. I wanted to ensure that the patient had received his medication ( although I knew if he hadn't he would have been recalled to hospital ) , so I asked him which side he had had his depot injection, say that I didn't add pressure to an area that could become sore. He had had his injection the day before , he was much more focused unless distracted, I made a note of this would plan any further sessions to be after his medication had been given. 

The students suggested a different technique which after session I discussed. the technique had involved leaning over the patient from that head and shoulders to make contact with the ribs, this would allow the patient to grab me potentially, which I discussed as being a high risk technique. I had opted to work from the legs up which although had the risk of being kicked I felt was less threatening than being grabbed and held. 

Feelings  

This was a challenging patient to have in clinic in many ways, and I have many conflicting thoughts in relation to it. 

On one hand I felt ideally placed to treat this gentleman as I had an understanding likely reasons he was placed on the section, and was very clear about the potential risk he presented. Most of the students most likely would not have picked up on the subtleties of his presentation and wouldn't know ask about the section or what it meant. 

I also felt as I'd left the mental health profession, I had “done my time” managing psychiatric risk, potential threats to myself. I understand obviously that any osteopathic patient can present with mental health problems. 

I also felt conflicted because clearly working from a person centred, bio psychodynamic approach, which is innate within me, I felt he deserved treatment as much as anybody else. As a person with severe mental health issues, he is likely to have suffered and experienced discrimination and ostracisation throughout his life. 

Whilst in mental health social work I strived to see the person beyond the diagnosis at all times, I was frequently confined by the remit of the Mental Health Act. Osteopathy sees the person as a whole too. 

What is apparent is that my very extensive training in mental health and risk assessment is still very clear and relevant, not just in relation to patients with paranoid disorders but also patients with “lower level“ mental health issues and anxieties. 

Gibbs, G. 1988 Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Polytechnic.

·         practitioners have to use fluid resistant surgical masks that can be used for a period of one session ( 4 Hours )

·         patients are recommended to use masks during the entire consultation to mitigate the risk of droplet transmission. if patients are exempt from wearing a face mask, practitioners are recommended to use a visor or eye protection.

·         practitioners have to use gloves during the entire consultation

·         after each patient practitioners need to clean all hard surfaces using the appropriate sanitising products.

·         After the consultation practitioners need to remove any PPE used and place immediately into a disposal bag.

·         It's recommended air exchange of the clinical environment at the end of each session.

If a patient is unable to wear PPE it's important to undertake a risk assessment where the practitioner is considering treating a patient. when making decisions, it is important to consider the potential benefits and risks for the patient, practitioner and others in the clinic. practitioners should discuss this public health issue in a balanced way with the patient.

As a student in clinic I took these guidelines very seriously and adhered to them at all times. I would point out lapses in adherence to these policies. 

The Institute of Osteopathy, 2021. Infection Cobtrol and Personal Protective Equipment (PPE) in Osteopathic Practive. Available at https://www.iosteopathy.org/wp-content/uploads/2021/12/Infection-control-and-PPE-in-osteopathic-practice-V9-Dec-21-update.pdf [accessed April 6^th 2022) 

63% of the population is considered obese or overweight, and this increases the risk of developing diseases such as high blood pressure and type 2 diabetes.  (Public Health England  2017 ). 

As healthcare professionals we need to be mindful of the link between obesity and additional health concerns and if possible support our patients in this area. 

Whilst in a clinical integration/ clinical safety lectures in the year 4 there was much discussion around cases that are included or involved prostatic changes, whilst this is important, and we were urged to ask all our male patients over 50 if they have had this test, there was no reference to asking female patients if they have had up to date smear tests and mammograms. 

I have since reflected on this imbalance of focus and have highlighted this to the tutor. 

As osteopaths, it is important that we cover all gender-related health screens as well as general public health considerations such as obesity, diabetes and hypertension. 

https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2 [accesses 9th feb 2022) 

 As part of the business plan module in year 3 we were asked to produce an ASA compliance advert – attached.

The conditions I have listed were based on the guidance of the ASA (2016). I feel strongly that it is immoral and unethical to claim osteopathy can treat conditions where there is no evidence to suggest this. Osteopaths must act with integrity, and we must be explicit about what we can and cannot treat, and offer solutions or alternatives. 

Advertising Standards Authority, 2016. Health : Osteopathy. 

Available at https://www.asa.org.uk/advice-online/health-osteopathy.html [accessed 6th April 2022) 

“a breach of sexual boundaries occurs when a healthcare professional displays sexualised behaviour towards the patient or carer” (Council for Healthcare Regulatory Excellence 2008,p2) 

Communication is key in this area to ensure that patients understand the process of examination and treatment to avoid misunderstanding and to gain full consent. Practitioners must respect patients modesty and dignity and understand the potential vulnerability of patients.Tthis vulnerability is demonstrated either through the information they have shared, the state of undress during examination, on the examination process itself (potentially). Practitioners need to have a high degree of self awareness and self reflection to avoid situations where their conduct could be misconstrued as sexualised. this includes words, actions and their own dress code. 

https://www.professionalstandards.org.uk/docs/default-source/publications/policy-advice/sexual-boundaries-report-on-education-and-training-2008.pdf?sfvrsn=afc77f20_8[ accessed 5^th May 2022). 

https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/duty-of-candour/ [accessed may 3^rd 2022 ) 

European School of Osteopathy. Providing feedback, suggestions and complaints. 

Available at https://www.eso.ac.uk/eso-clinic/feedback/patients-complaints-procedure/ 

[accessed on 3^rd February 2022)

In cases by osteopath need to share patients confidential information with other healthcare professionals they must have permission of the patient explaining what information and why they need to share this information. (OPSD5.7) (GoSC 2018). 

We must be GDPR compliant at all times.

I will always respect patients confidentiality and follow the guidelines This is particularly important in student clinic, where fellow students and friends of staff attend for treatment. it is imperative that they are afforded the same levels of confidentiality.  

https://www.osteopathy.org.uk/standards/  [accessed January 3^rd 2022]

Diversity requires a recognition an understanding of different background beliefs and experiences to your own. 

Patients must not be discriminated against or excluded from care or treatment based on these characteristics. in relation to osteopathy we look at the person as a whole, and this must include diversity to have a true sense of the person. To ignore diversity is to ignore a part of the person, and this is not osteopathic practise. 

·         I will ensure best practice and treatment for all my patients regardless of their diversity, or better perks because of their diversity. 

·         I will challenge anti-diversity practise and attitudes should I come across them either in student clinic or private practice. 

Equality Act 2010. Available at https://www.gov.uk/guidance/equality-act-2010-guidance 

·         I have already taken steps to limit access to my private social media and will continue to do so. 

·         I will not post social media content that could show osteopathy in an unfavourable light. 

·         I will not falsely advertise benefits osteopathy that are untrue. 

Excerpt from my business plan assignment. 

Because Maidstone has a large number of osteopaths, I have based prices on competitors’ prices (see previous page) and offerings, rather than what I need to earn, so that I don’t price myself out of the market. I will not charge more for Saturday mornings. My appointment times will reflect my competitors’.  

In this assignment, I discussed analysing my competitors' prices locally and placing myself on a comparative level price-wise (see table above). I felt this reflected my experience and my value, whilst not over-inflating my prices. Not all competitors had pricing on their websites.

·         I will have clear and visible pricing that is easily accessible on my website and social media platforms.

·         I will be clear about the pricing of any additional services at the point of delivery, ie KTape etc. 

·         I will offer all patients a receipt

·         I will use a database such as Cliniko to manage my invoices a tax return. 

·         I will be mindful on how promotions are viewed, in order that there is no misunderstanding of what is involved and offered. 

Attached is the handover sheet that I completed to hand over to a third year student. 

I tried to be accurate and succinct in my handover notes, highlighting presenting complaints and associated factors, working diagnosis, treatment and medical history. I also included treatment types the patient best responded to. I will aim to speak directly to the new practitioner and if possible arrange a joint session where I can introduce the student to the patient. 

By ensuring a smooth handover both in writing and hopefully in person, this is working within person centred approach and also allows student to understand the patient as much as possible to ensure a smooth handover. 

Reflecting on handovers to myself that have gone well and less well I will try to ensure the best possible handover and continued high quality care for my patients.

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

I have a 52 year old female patient in clinic who presents with a multitude of conditions including fibromyalgia , degenerative disc disease, asthma and is morbidly obese. She has had two gastric bypasses which have failed, and she's not motivated to move because of the pain she experiences. She comes into clinic every four to six weeks for treatment which she feels benefit from for two to three days. 

She started off as a cover patient from a colleague who is experienced frustration due to her lack of motivation to exercise and chose to stay with me. She had been coming to clinic since 2006. somehow the fibromyalgia didn't feature in the working diagnosis and I only discovered it through a deep read of her case file. Realising that I didn't know very much about the condition and that I may have a CEX with her, and wishing to provide the best care I consulted a colleague who had done a dissertation on the subject. I also researched online at the American College of  Rheumatology guidelines 2010. This helped me understand the different modalities that could benefit her.

In addition, I was attending the Osteomap course within clinic, with this patient in mind.

I reflected on this patient, who appeared to elicit feelings of frustration from practitioners who had treated her. I felt I could understand some of her psychological barriers to the suggestions of exercise, and attempted to positively reframe this to her. Carrying out the research into fibromyalgia insured that I had a better understanding of the condition and how I could help my patient, and future patients. 

I will consider what opportunities other disciplines can offer in relation to this patient and others

I will consider a referral to Osteomap, to ensure she has access to a psychological approach to managing and accepting pain.

I acknowledge the osteopathy whilst beneficial for so many, may not be enough on its own and other interventions may be needed.

https://www.rheumatology.org/Search/sb-search/fibromyalgia/sb-bhvr/1/sb-logid/344974-qoyzg395dq536s66 [accessed 12/12/21]

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

I will use Rolfe et al (2001) to reflect. 

The government guidelines have changed around COVID 19 rules which meant someone who was in touch with a positive contact did not have to isolate. My son tested positive for COVID and the rules meant therefore I could go into clinic and treat patients. 

Whilst legally I did not have to isolate and could have contact with patients, I felt that this was ethically wrong. We have many vulnerable patients in clinic, and despite wearing masks there still is a risk of transmission of the virus, particularly given how close contact we get to our patients. Therefore, I took the decision to contact clinic to say I would not be in that week. I want you to ensure that despite testing negative myself I was not putting patients and colleagues at risk, in case I was positive. I am aware that my colleagues had to cover my patients whilst I was off, and this may have been inconvenient for them and the patients, but on balance it was the right thing to do. 

I feel this was the right action to take at the time, despite what the government guidelines said.

I still believe I had a duty of care to my patients and my colleagues

I will continue to ensure that my health does not have a negative impact on my patients health and well being.

Rolfe,G., FreshwaterD., Jasper,M. 2001. Critical Reflection in Nursing and the Helping Professions.: a user’s guide. Basingstoke: Palgrave Macmillan. 

I will advise GOsC of any changes and comply with instructions given. 

Suspected Cauda Equina Syndrome.  

A female patient attended the clinic with a very complex set of symptoms, including Complex Regional Pain Syndrome, burning hips, abdominal pain ,neurological symptoms and she was waiting for a urine test results. The case history took all of the session and whilst I offered to test the patient, I said we would not be able to treat her that day.  She said she would like to come back the next week. 

She returned the following week and I had in the meantime considered if her symptoms may be early MS so I asked some specific questions about that. Through this further questions she said she had some saddle anaesthesia the previous weekend but that it was “ok” now. Whilst summarising the information I had I asked her again if she had any saddle anaesthesia and she replied “no not really”. I needed to know this information as I was obviously trying to illicit if she had Cauda Equina Symptoms . Given the seriousness of the situation I said “ I don’t feel your are telling my the whole picture “ and re-explained why I needed her to be honest. She started to cry and said that she had progressive saddle anaesthesia, as well as other worsening neurological symptoms. 

I took her BP/pulse and explained I needed to carry out some tests to check her nerves and work out a plan.

I struggled to get a reflex on her knee as she had had three knee replacements and myotome testing was causing a lot of pain. She asked to sit up and I said I would ask my tutor to come in and advise me. As she was sitting up legs outstretched on the couch whilst she adjusted herself, at that moment the tutor knocked and entered the room. He immediately told me to move my patient and I explained I was in the process of this. He asked me what results I had obtained so far to support our thoughts, he was very blunt and loud. I explained the patient had been crying and I had only got as far as the blood pressure and reflexes.

He then asked me if he could do the neuro screen which I agreed to, as I was going to ask him to help me anyway. 

We went to the clinic group room and he continued to be very loud in his interactions, whilst appearing to tell me what  I had already told him, i.e. I suspected Cauda Equina Syndrome.

We agreed she should be referred to A&E. I started to write the letter with tutor coming in and out of the room distracting me. 

After she had left he said “what feedback do I have for you“ in a similar tone. I replied I would like some feedback as I had not had a Cauda Equina case before. 

His main points were

·         My neuro screen wasn’t focussed

·         I was too concerned with her pain 

·         And I had left her in an uncomfortable position

My response was 

·         I acknowledged my neuro screen wasn’t as good as it should have been.

·         I very strongly asserted that I had obtained information that not all students would have got, to enable me to identify the condition

·         I had to take time to explain to her what was going on and why we were concerned.

·         I explained she must not minimise the symptoms in A&E.

·         I gave her time to ask questions and to compose herself.  

·         I reiterated the position the patient was in when he entered the room, and why. 

I felt I managed the situation well, although I acknowledge my neuro screen was not as good as it could be. 

I felt the tutors’ stress came across as aggressive and was not helpful in the situation. Given his experience, I felt he should be able to manage his stress more effectively so that I as a student can maximise my learning and feel supported. 

Fortunately, my previous career was very stressful and I am used to working under pressure. I reflected on whether the tutor took my calm approach as not understanding the gravity of the presentation, when in fact that is how I work under stress, and I was very clear about the seriousness of the situation.

The feedback felt like an attack and I had to robustly defend myself multiple times, as I felt I was not being listened to, in relation to

·         The unfortunate timing of the tutor entering the room and his perception that I had left my patient in a painful position when I hadn’t 

·         That I had been assertive with my patient to ascertain the symptoms she was not telling me, in order to conclude my diagnosis of suspected Cauda Equina, which other students may not have. 

·         And in relation to my next patient that was still waiting, I fedback that maybe that could have been considered by him earlier rather than after leaving her for 15 minutes and then it being my suggestion that another student sees her. 

In summary whilst I will take on board the tutor’s feedback about my neuro screen,  I felt I managed this situation well despite the added impact of the tutor’s stress and agitated state. I worked to the best of my ability in a stressful situation, trying to filter out the tutors stress and noise. I would have liked a balanced debrief before leaving the clinic as I felt the tutor thought I was lacking, and this is not a helpful so close to CCA