Chapter 33 Facilitating clinical decision making in students in intercultural fieldwork placements
Health professional education is increasingly being undertaken in intercultural settings, in both domestic and international contexts. Such intercultural contexts are both more complex and more demanding than the familiar environments in which students in the health professions typically find themselves. Clinical reasoning within such complex practice settings presents significant challenges for all healthcare practitioners, not only for students. Despite the challenges inherent in intercultural settings, there is a relative paucity of information on best practice in facilitation of clinical reasoning and decision making in such contexts. This chapter draws upon data gathered over several years spent developing, implementing and evaluating an interdisciplinary student fieldwork programme in Vietnam. Using extracts from research interviews undertaken with students about their learning experiences in Vietnam, the chapter illuminates the demands and tensions experienced by students. It also outlines processes and strategies employed by fieldwork educators to facilitate students’ clinical reasoning in intercultural settings. We present recommendations for academics and fieldwork educators for facilitating the clinical reasoning of students in intercultural fieldwork placements, and conclude with reflections on the future of intercultural fieldwork, clinical reasoning and research.
Since 2001, the School of Community Health at Charles Sturt University’s (CSU) Albury campus has been conducting an international multidisciplinary allied health fieldwork programme involving children with physical disabilities at Phu My orphanage in Saigon, Vietnam. Each March and April, up to 12 final-year occupational therapy, physiotherapy and speech pathology students, with rotating fieldwork educators from these disciplines, spend 6 weeks at the orphanage. One goal of the programme is to educate and train Vietnamese staff in the orphanage (Vietnamese-trained physiotherapists, paediatricians, teachers and carers) about optimizing feeding, communication, play, mobility and other activities of daily living with children with physical and intellectual impairments. The aim is not to ‘treat’ or provide direct therapy to individual children, except when modelling skills and supporting capacity development for Phu My staff. The second goal pertains to student learning issues. Students are expected to develop intercultural competence and a range of other basic competencies including Vietnamese language skills and knowledge of Vietnamese history and culture; skills in training and working with interpreters; working with children with physical and intellectual impairments; training and educating others (Vietnamese staff, other volunteers at the orphanage, CSU students from other disciplines); managing team dynamics and group processes; working in resource-poor environments. The term ‘intercultural competence’ refers to cultural self-awareness, knowledge of ‘the other’, and skill in mediating communication (Sodowski et al 1994).
An ongoing research programme has been in place since the inception of the Vietnam project, one aspect of which uses a critical incident approach (Fitzgerald 2000). We interviewed students in the country and/or upon return to Australia about their experiences in Vietnam. The critical incident approach, a specific narrative device through which meaning is ascribed to a significant event via guided reflection, was chosen because it provided a contextually sensitive means through which the students could make sense of both their clinical decision-making processes and their multilayered interactions with Vietnamese staff. Preliminary findings of this research have been reported elsewhere (McAllister et al 2006; Whiteford & McAllister in press).
Within the distinct milieu of Phu My orphanage, effective clinical reasoning and decision making are requisite to the success of the programme. As a fieldwork site it is complex and demanding because of the sociopolitical environment, the attendant intercultural interactions, the interdisciplinary nature of the placement and the complex needs of the children and staff of the orphanage. Students and fieldwork educators interact daily with large numbers of children and staff, responding to different and at times competing requests for help and advice. Higgs & Jones (2000) have described several approaches to conceptualizing clinical reasoning. Because they are neither fluent in the language (needed to elicit case histories) nor able to perform detailed diagnostic assessment, students appear not to use hypothetico-deductive and pattern recognition approaches to reasoning, which are perhaps more appropriate to the delivery of treatment in like cultures and treatment within medical contexts. Students and health professionals in intercultural contexts, such as that of the orphanage, need to use complex approaches to clinical reasoning and appear to use interpretive approaches, particularly the interactive, narrative, collaborative and ethical/pragmatic approaches to reasoning outlined by Higgs & Jones (2000), derived from research in occupational therapy (Fleming 1991) and physical therapy (Edwards et al 2004).
The client-centred model of clinical reasoning described by Higgs & Jones (2000) best describes the approach to clinical reasoning sought in the Vietnam placements. The client-centred approach involves the application and integration of cognition (thinking about the clinical problem), professional knowledge, considerations of the environment, clients’ input (in this case preferences expressed by children and requests from staff), and metacognition (monitoring one’s thinking and the interaction of all the factors mentioned earlier – especially important in the intercultural setting). In our case, the clinical problem might be a child’s needs for mobilizing, play or self-care, carers’ needs for training, or determining how to enrich the children’s environment. Within the context of this client-centred reasoning model, students have relied most significantly upon processes of narrative reasoning (Mattingly 1991) to articulate and refine their clinical decision making. Narrative reasoning often entails practitioners creating or sharing stories about their work. The self-talk or talk with others involved can mediate metacognitive processing and promote deep learning through creating opportunities for critical reflection (Brookfield 1990). For students in the complex intercultural environment, narrative reasoning is particularly relevant and offers an appropriate medium through which to plan, articulate and evaluate both their professional goals and the overarching goals of the programme. Group reflection (discussed later in the chapter) is therefore an important aspect of the programme.
The propensity for students to employ narrative reasoning processes naturalistically, in response to the specific demands of the setting, reinforced the appropriateness of the adoption of a critical incident approach to programme evaluation. It allowed us to capture rich narratives and thick descriptions of intercultural interactions and the nature and demands of clinical reasoning and decision making in situ. An excerpt from one such critical incident interview is presented here as an exemplar of the experience of being in a complex intercultural environment and doing continuous reasoning.
We present an excerpt from an interview with John, a physiotherapy student. This interview was conducted early in John’s placement in Vietnam. The child John refers to has severe physical limitations due to cerebral palsy.
… after doing a little bit of an assessment and playing with one of the children we began to feed the child and I was actually feeding the child and taking a lot of time because the child was feeding very slowly and then the carer came in and took over and said ‘let me show you how to do it’. She then sort of grabbed the child’s head, pushed his head back, shoved the spoon straight down his mouth and continued shovelling in and this was very disturbing for me and in fact I even had to leave the room. … I found it upsetting, I felt helpless because I’d lost control. I also felt that I’d failed in my job of feeding the child in that the carer had to come in and take over. And I felt that I had sort of lost face through that. I’ve since repaired that, but it was difficult on that level, the relationship with the carer, but I also felt very much for the child. You could see the child protesting … showing some obvious signs of distress. Hands pushing away, head turning away, mouth clenched closed, all those things, but the food was going in there regardless. … I wanted to step in but I had to recognize my professional boundaries. That was the sort of relationship that the child had with the carer and that’s how he’s probably fed a lot of the time, so I had to step back and that was very difficult to do because I would usually jump in there before I’d think about it. So I actually had to think and stop and say no, the right thing to do would be let him be fed by the carer as the carer wants to at this stage and slowly work at [changes] rather than try and change things all at once. It was difficult, it was difficult for me because I like to jump in there and do things. … She’s the chief carer in that room and someone we have now developed a really good relationship with and she’s very receptive to the work that we’re doing. I’m now regularly feeding a different child and she’s allowing me much more time to feed with that child. There’s food going everywhere, we’re making a terrible mess but she’s okay with it, she’s fine because I’m cleaning it up. So I can see the benefits of what I did at that stage. If I had got upset in front of her or tried to change forcefully what she was doing that would have had a negative consequence. I can see now that she’s much more receptive and she’s come around to what we’re doing. … [On reflection] apart from the obvious language barrier there were the cultural issues, I think it was really the ‘save face’ kind of thing. I was aware of [it] in Asian cultures in terms of being seen to do something or recognizing your own limitations; I guess [there] is a point to it as well and being able to ‘save face’ rather than, you don’t want to be humiliated. So the honourable thing I could do in that situation was to withdraw. If I hadn’t I would have offended her, as I would have probably someone in any culture but particularly I think here, they are very sensitive to it. And probably then there would be the male…female dynamics as well, that would have definitely, definitely been an issue. Had I said anything at that stage she would have definitely resented it as to ‘who are you? who do you think you are? you guys know nothing about what we’re doing here’.