The College uses the “Do. Learn. Grow.” phrase when discussing continuing competency for physiotherapists. Continuing competency is not just about clinical skills but also the skills that are non-technical in nature. The recently revised Managing Challenging Situations Guide1 reviews the components that lead to a challenging situation, what to do when you find yourself in a challenging situation, and the importance of learning from the situation and growing as a physiotherapist. Challenging situations occur in a wide variety of contexts, and it is important that as a physiotherapist you have the knowledge and skills to address them in a manner that is respectful, professional, and meets the expectations of the profession.
The guide provides a place for physiotherapists to start when learning about or working through challenging situations. In this article, we will provide an overview of the content of the guide by getting to know a patient named Melanie and a physiotherapist named Corey and the underlying factors that contributed to their challenging situation. We will also look at how Corey reviewed and reflected on the outcome of that situation and how it could have been potentially avoided.
The Situation:
A breakdown of their challenging situation.
A challenging situation can be any situation that gives a physiotherapist pause or puts them in a position of uncertainty or conflict. More specifically to physiotherapy practice, it would be any situation that affects their ability to deliver quality, safe, and effective care to their client.
The Physiotherapist Perspective:
Corey greets Melanie as she arrives late for her appointment and is hopeful something has changed with her symptoms. During the subjective history, it is apparent that her symptoms haven’t changed and Corey’s frustration with his inability to obtain positive results over the past 6 weeks flows over and he decides that it would just be easier to discharge Melanie to someone else. Without putting much thought into it, Corey tells her that the physiotherapy treatments they have been using are not working and that she should look for another physiotherapist who can “deal with her better”. As soon as he says this and sees Melanie's reaction, he realizes that the message, his tone, and body language are not appropriate for what he is trying to convey to Melanie. When Melanie starts to raise her voice and list off her frustrations, Corey is speechless as this is not what he expected to happen. Before he can come up with something meaningful to say Melanie exits the treatment room.
The Patient Perspective:
Melanie is a bit flustered after arriving late to her appointment again and is frustrated when she is asked the same questions as always when she sits down with Corey. She answers his questions and gets the feeling that Corey has given up on her. She is thinking about her frustrating morning, her headaches, and how she has been rushing to get here every Monday for her appointments when Corey tells her to see someone else who can “deal with her better”. She gets very upset at Corey for his perceived abandonment of her care and is now thinking of how she is going to find another physiotherapist and start treatments all over again. She begins to list off her frustrations with her care and how Corey doesn’t seem to be interested in helping her. She is wondering how it got to this point and when Corey doesn’t respond to her, Melanie figures that he really has given up, so she gathers up her stuff and storms out of the clinic.
The morning of:
A small glimpse into the thoughts of the patient and the physiotherapist prior to the treatment session.
Challenging situations do not pop up out of nowhere. There are always factors that contribute to the development of a challenging situation. The patient, the physiotherapist, and even the work environment can all be a part of it. The physiotherapist and the patient can both be experiencing stressors, burnout, frustration, and their own lived experiences that can alter the perception of and reactions to an event. At the practice site there can be issues with workplace morale, lack of time and resources, as well as administrative issues that can all lead to stress and pressure on the physiotherapist and the patient. Though it can be difficult, physiotherapists are always expected to act in a professional and respectful manner to their patients and the public. Patients have a bit more leeway when it comes to expressing their feelings or frustrations, however, this shouldn’t become disrespectful or abusive.
The Physiotherapist Perspective:
Corey is waiting for his patient to show up for her appointment. He is frustrated because she is always his first appointment on Mondays and is never on time. He realizes that his day is completely filled up and another staff meeting that should be an email is scheduled during his lunch break. Melanie’s lateness is going to cause issues for the rest of his morning as he tries to play catch up with the rest of his patients. He also realizes that her subjective reports haven’t changed much lately, and he is struggling to come up with any other treatment options to recommend. He has been putting off a pain management course for the past year as he is trying to pay off his student loans and is feeling like he could really use it right now. He is not looking forward to seeing Melanie to start his day.
The Patient Perspective:
Melanie arrives late for her appointment with Corey. She just dropped her daughters off at daycare and school and was rushing to get to her appointment, but she doesn’t ever seem to be able to arrive on time. Her headache is really ramped up today and she didn’t sleep well last night because of it. She thinks that it’s been 4 months, shouldn’t the headaches be gone by now? Initially, things were going well with all of her other injuries, but for the past 6 weeks, the ongoing headaches have been a struggle. She sits down hoping that Corey will talk to her about changing her treatment as she finds the needling to be more aggravating than anything else. She has been doing the same home exercises for the past 6 weeks with no improvements. She knows she hasn’t been as diligent with the exercises as she should but between work, kids, and everything else she struggles to fit it all in. Everything seems to be putting her more and more on edge. As Corey comes to greet her in the waiting room, she notices once again he seems grumpy or frustrated when she is there.
As we can see from both the patient's and the physiotherapist’s perspective, many factors contributed to Corey’s impulsive comment and Melanie’s reaction. Could some of these issues have been proactively dealt with? Could some of the negative outcomes from this conversation be avoided?
After the Challenging Situation:
Self-awareness
The Managing Challenging Situations Guide has a large section devoted to self-awareness and self-reflection so that physiotherapists have an opportunity to learn and grow from their experiences. Going through challenging situations can be awkward and even intimidating. However, if you can learn from them and try to increase your awareness of both your and the patient’s perspectives then hopefully you can catch most issues before they start to negatively affect the therapeutic relationship. This section will focus on the physiotherapist and their responsibility to learn and grow from these experiences.
The Physiotherapist Perspective:
Corey realizes that he managed his interaction with Melanie poorly and is upset with what occurred. He is now feeling like he let her down and is dwelling on the exchange they had in the clinic. He realizes he did not handle the situation well and is looking to figure out what he could have done differently during the conversation, what to do now, and what to do next time a situation like this is developing.
He looks at the Managing Challenging Situations Guide and starts reading about self-awareness. From the guide, he reads about the Thomas-Killman Conflict Model² and realizes that he may be a bit of an “Avoider” and was pushing off his responsibilities to have an honest conversation with Melanie regarding her lack of progress and her consistent late arrivals to their appointments. In retrospect, he was also putting off altering the treatment plan that was no longer effective. His tendency to avoid conflict also caused him to not engage in the discussion when Melanie was upset. Not wanting to deal with all of these concerns directly led to the poor outcome of his and Melanie’s therapeutic relationship.
After the Challenging Situation:
Self-reflection
As part of the “Do. Learn. Grow.” model the College uses for continuing competency, self-reflection is an integral part in which the “Learn” becomes the “Grow”. There are many times when opportunities are missed by failing to take the time and energy to meaningfully reflect on a situation that didn’t go as smoothly as possible. Sometimes it’s a small tweak or it can be a much larger reflection on one’s beliefs and attitudes towards patient care. Regardless, self-reflection is a significant part of managing a challenging situation. Again, as it is Corey’s responsibility to learn and grow from this, we will look at this from Corey’s perspective.
Physiotherapist Perspective:
After reading the Challenging Situations Guide, Corey puts together a list of things that were in his control that could have led to a better outcome from the therapeutic relationship.
1. Recognize the patient’s perspective
- Melanie has been dealing with multiple stressors in her life.
- Could have been more understanding of her late arrivals, worked with her on potential solutions with our admin team.
- Provide more opportunity to discuss her treatment plan and get feedback.
2. Altering the treatment approach
- Getting limited results in improving her symptoms.
- Altered treatment strategies or exercises.
- Provided self-management, pain-management resources.
- Consulted with other physiotherapists for different perspectives.
- Referring on is a potentially viable option but better plan/communication to Melanie.
3. Planning
- Planned the conversation and main concerns with Melanie’s condition/lack of improvement.
- Planned for the various potential reactions from Melanie.
- Ran through this with another physiotherapist to get their perspective.
4. Said something during the conversation at today’s appointment
- Missed the opportunity to reassure Melanie that I wasn’t abandoning her care.
- Should have reviewed Melanie’s care with her and discussed both her and my thoughts.
- Continued the conversation to figure out how to address her care better.
The Chance to Travel Back in Time:
“Learned. Grew.”
In this situation, there are multiple possible outcomes had Corey incorporated a more thoughtful approach. Maybe it would have resulted in a similar outcome, but the chances of that are lower if Corey had been more thoughtful and proactive in the preceding weeks and had planned the conversation.
How could this situation have been different?
- Corey recognizes Melanie is stressed, in pain, and frustrated.
Corey greets Melanie and during the subjective interview reads the verbal and non-verbal cues that Melanie is feeling very frustrated, is currently experiencing a bad headache, and has just rushed to the clinic trying not to be late again. He decides today isn’t the best day to spring any change on Melanie but takes the next 15 minutes just to talk to her about her treatment plan, her thoughts on how physiotherapy is going, and how she views her pain and what some barriers to improvement are.
- Corey suggests a change in treatment approach.
Corey recommends to Melanie that they reassess her today and review some of her main concerns with the treatment plan and what she thinks are barriers to getting better. Then, Corey will spend the next few days reviewing her care plan, talking to some other physiotherapists about her treatment, and will send her some short videos with information on pain, pain-management, and self-management.
Perhaps they redo the treatment plan with some options that could work for Melanie and decide to start fresh next week. Corey also reduces some of the exercises to just a couple of simple ones she can do while in the office or sitting on the couch after the kids are in bed.
- Corey recommends that Melanie should see another physiotherapist.
After evaluating her treatment plan, his current competencies as a physiotherapist, and Melanie’s current symptoms and condition, Corey thinks he needs to refer Melanie to another physiotherapist and a chronic pain clinic. Corey plans out the discussion in advance and has steps in place to deal with some of the potential outcomes when he makes the recommendation at Melanie’s next appointment. During the conversation, Melanie still gets upset but Corey can maintain his composure, talks calmly to Melanie about the reasons for his recommendation, acknowledges her feelings, and they agree that she will start next week with another physiotherapist at the clinic who has more experience and education relating to chronic pain and whiplash.
The Wrap-Up:
The Managing a Challenging Situation Guide
The Managing a Challenging Situations Guide is a resource that physiotherapists can use to assist them when they encounter a challenging situation in practice. The Guide has sections on what to do when you are in a challenging situation, reviews the anatomy of a challenging situation, and discusses common challenging situations physiotherapists may encounter in practice as well as some insights on how to manage those specifically.
This article was a brief introduction to the Challenging Situations guide and highlighted a situation in which the predisposing factors played a major role in the formation of a challenging situation. This article also discussed the role that self-awareness and self-reflection can play in how one can become more adept at managing a challenging situation.
While this article employed Corey and Melanie’s conflict as a case study, the best scenario is to avoid challenging situations altogether by developing self-awareness and addressing contributing factors that the physiotherapist can influence. Review the revised Challenging Situations Guide for more information.
If you find yourself in a challenging situation that you are unsure of how to manage, you can review the Guide or turn to the College’s Practice Advisor for assistance.
References
- The College of Physiotherapists of Alberta: Managing Challenging Situations Guide. https://www.cpta.ab.ca/for-physiotherapists/resources/guides-and-guidelines/managing-challenging-situations-guide/
- Dotun Ogunyemi, MD; Susie Fong, BA; Geoff Elmore, MD; Devra Korwin, MA;
Ricardo Azziz, MD The Associations Between Residents’ Behavior and the Thomas- Kilmann Conflict MODE Instrument. J Grad Med Educ (2010) 2 (1): 118–125. https://doi.org/10.4300/JGME-D-09-00048.1
