Clinical education requires a seamless transition from classroom to clinic1. However, some students struggle to integrate affective domain skills and have difficulty applying generic abilities1 during real-time patient care. Generic abilities include interpersonal skills, professionalism, stress management, and commitment to learning. These can be difficult to measure and even more difficult for faculty members to talk about.1 In response to these deficits, Wolff-Burke2 and colleagues3 coined the term “Generic Inabilities” to describe unprofessional behaviors of student physical therapists (PTs). These behaviors included poor communication, lack of interest, arrogance, irresponsibility, poor patient rapport, unresponsiveness to clinical instructor (CI) feedback, and poor critical thinking during patient care.3 To date, it remains unknown how students think as they near failure, how they conceptualize it, and how they reemerge to find success and graduate.
In response to similar concerns,4–7 physician educators8–15 developed mindful practice, defined as a purposeful awareness of one's internal affective states, practiced regularly, to enhance the intrapersonal relationship with oneself.14–18 This internal relationship has a direct influence on performance because it provides immediate information about emotions.9,11,18 The opposite of mindfulness is mindlessness, characterized by multitasking, self-deception, covering up deficiencies, excessive reliance on facts, excessive speed, and reactivity.10–12,16 While mindfulness has been added to the formal curriculum in medical training,13 occupational therapy,19–21 and psychology,12,22 little direct application has been studied in the field of physical therapist education.
The purpose of this phenomenological study was to explore the personal accounts of 8 physical therapists that failed a graduate school clinical education course, remediated, and graduated successfully. Given the context of mindfulness theory and practice, research questions inquired whether mindless thoughts, feelings, and behaviors occurred prior to failure (Appendix A), and whether mindful thoughts, feelings, and behaviors occurred after remediation and success (Appendix B).
Distinctions Between Reflective Practice and Mindful Practice
Some authors conflate reflection in action with mindful practice. Schön23 first described reflection in action as appraising or thinking about an activity while engaged in it,23–25 whereas Epstein10,11,14,15 defined mindful practice as a purposeful awareness of internal affective states. Both, therefore, encourage students to examine their own values and beliefs, formulate thoughtful questions, and consider the health care environment as a whole.25 However, despite some apparent commonalities, there are distinct differences between them.
Functional MRI studies26,27,29 have demonstrated that users of mindful practice activate different neural circuits in the brain. Mindful practice teaches students to develop an interoceptive awareness by pausing to focus on the body.22,26,27 In doing so, right brain structures promote self regulation with awareness of thoughts, feelings, and body sensations.29–31 The insula cortex, critical for self-assessment, feeds this information forward to the prefrontal cortex in what is described as a “functional shift” to the left brain or executive functioning centers.18,26,29,32–34
This way, users of mindfulness learn to attend to their thoughts and the effect these have on the body so that they can act with awareness. In contrast, the “default mode,”27,29 characterized by midline neural circuitry, automaticity, and poor self-awareness, allows personal narrative, memory bias, and other stress reactions to dictate the outcome.18,27,30,34,35 To illustrate, a student who is about to enter a patient's room may pause intentionally to notice their thoughts (fondness/aversion) and the associated senses within their body (openness/tightness). In mindful practice, they are taught to name these thoughts (“here is uncertainty” or “here is worry”) and proceed with this awareness. Once the student names the thought or feeling, it becomes an objective piece of information, thereby losing its power in the moment.18
Mindfulness theory and practice is based on eastern teachings and is considered “a way of being”9,32,37 rather than a cognitive ability.32,34 Therefore, the intentional self-focus prior to, during, and after patient care extends into all areas of life, stabilizing over time.37 In contrast, as reflective practitioners, students are asked to engage in a more singular patient focus prior to, during, and after patient care. This attention is ever-changing37 and must adjust based on incoming information and patient needs.25 Although both have been shown to complement clinical reasoning during patient care,10,11,13,25,35,38 mindful practice affords the user direct and lasting methods to identify and manage emotions,13–16 which has been shown to prevent physician error, improve attitude, and develop empathy for self and for others.13
Mindfulness: Mechanisms of Action
Mindfulness promotes presence, defined as a focused awareness in the moment.9,15,22 Presence allows an individual to see a situation for what it is, rather than being influenced by personal subjectivity.22,39,40 This allows an individual to place fewer conditions on experiences, categorizing them as “good” or “bad.”41 The result is a tolerance for ambiguity and a decrease in emotional reactivity.39,40,42
Students experiencing daily stressors may have negative thoughts and feelings while feeling powerless to respond to these, given that they must perform to meet a standard.16 Typical stress reduction techniques, such as relaxation training, do not decrease rumination, a common byproduct of worry.43 Mindfulness allows the student to notice their thoughts and pause to redirect the focus to the breath.9,22 This way, the breath becomes a readily accessible anchor to interoceptive awareness, which decreases the sympathetic response to the stressful thought.9,22 As the student notices the thought and the influence on the body, they can decrease judgment of the experience,22, thereby decreasing rumination.43,44,49 Once rumination stops, potentially escalating emotions become impermanent events that are separate from the self.44–46
Conversely, inattentiveness to inner responses creates overreactions to affective stimuli that may lead to undue sadness and worry.47–50 Mindful practice does not claim to disregard or stop thoughts or feelings.38,49 Instead, it serves to identify these (“here is anger”) to prevent further elaboration of negative emotions.50,51 This way, mindful practice (1) prevents errors,52 (2) decreases hurried encoding,53 (3) decreases multitasking,54,55 (4) stimulates critical thinking,52,54 (5) increases resilience under stress,52 (6) increases approaching behaviors,22,54 (7) quiets the inflated ego,56 (8) increases well-being,57 (9) improves emotional awareness,46 and (10) promotes clear decision making.18,55,58 Mindlessness, however, serves a distinct purpose for the struggling student, preventing anxiety-based uncertainty36 and allowing fragile ego involvement58 to block accurate self-assessment.24,59
Emotional Response to Failure
The concept of failure in graduate students includes (1) elements of shame,59,61–64 (2) insecure striving or inferiority,65 (3) difficulty forecasting errors,41 (4) excessive goal attainment,66,67 (5) errors from overestimating the impact of failure,41 (6) mind wandering due to stress,4 (7) negative affect,61 (8) fear of rejection,62 (9) feeling internally deficient,63 (10) maladaptive perfectionism,5,6,64 (11) self-consciousness geared at diminishing negative emotions,45 and (12) resultant fear, which produces defensive behavior.8,9,11 Under stressful conditions, self-assessment becomes inaccurate.28,33,69 However, awareness of internal dialogue (self-criticism) influences the response to failure, even in novices,68 and develops the ability to learn from mistakes.9,13,68
Purposive theoretical sampling was used in the recruiting process to ensure that none of the participants had prior knowledge of mindfulness. Institutional review board (IRB) approval was obtained. Directors of clinical education (DCEs) of 8 accredited physical therapy programs from a single state in the Northeast were contacted to identify potential subjects. Each agreed to contact past students who had failed a clinical course and graduated within the last 5 years. The DCEs then e-mailed potential participants a letter of intent from the principle investigator (PI).
The following inclusion criteria were shared with the DCEs upon initial phone contact: (1) presence of failure in 1 clinical education course, (2) remediation due to deficits in generic abilities, (3) repeat of the failed clinical, and (4) successful graduation within the last 5 years of the study. Eleven participants agreed to participate, while 3 were excluded for the following reasons: 1 had not completed remediation, which was a requirement of this study, another had not yet graduated, and the third was excluded because he shared significant negativity toward his academic institution.
Remediation processes were not investigated due to wide variability, but all participants shared that remediation was required of them for deficits in patient safety, professionalism, interpersonal skills, stress management, and communication. Examples of remediation activities included written reflection on what they would do differently in their next clinical experience, active listening exercises, learning to accept feedback, principles of patient-centered care, case studies, and practical skills tests.
DCEs made all initial communications using the investigator's letter of intent. It is unknown therefore, how many total students were invited to participate. Eight remaining participants agreed to participate in a face-toface interview, lasting 1–2 hours each. Selfselected pseudonyms were used to protect participant identities. Participants included 5 males (2 Asian and 3 Caucasian) and 3 females (1 Asian and 2 Caucasian) between the ages of 25 and 30 years, with an average grade point average (GPA) of 3.7. Of the 8 participants, 5 had graduated within 1 year, 2 had graduated within 3 years, and 1 had graduated within 5 years. This sample size was consistent with previous phenomenological studies in physical therapy research.70–74
Phenomenology is a philosophy and methodology that explores a participant's lived experiences. The focus in this case is on experiences of what failure means in the context of mindful practice and clinical education.71,72 As part of the phenomenological process, personal biases were identified through reflexive bracketing.71,74 Prior to data collection, biases and assumptions were journaled.73
It was vital to select participants who had never heard of mindfulness. In doing so, personal statements remained truthful in their construction of past events while maintaining the purest form of the phenomenon of failure. The PI was aware of the need to adhere to the interview guide (appendix C) to remain focused on the phenomenon rather than the interpretive framework.76 Interview questions closely approximated the wording used by the Kentucky Inventory of Mindfulness Skills (KIMS), a self-report inventory used to assess 4 mindfulness skills, including observing, describing, acting with awareness, and accepting.75
Because the investigator was a novice phenomenologist, interviews were practiced with experienced qualitative researchers using the interview guide until the investigator could demonstrate a continual return to the participant's lived experience of failure, which would allow the textual expression to speak for itself.73 The PI transcribed digitally recorded interview data on a password protected laptop. Data was explored for indicators of mindlessness (excessive categorization of material, oversimplification, automaticity, ignoring the obvious, avoidance, covering up deficiencies, premature closure, denial, and high ego)11,12,16 and mindfulness (pausing, observing, acting with awareness, describing/labeling, self-compassion, and non-judging)10,12 prior to, during, and after the failure event.
Data analysis included reading and rereading transcribed data for common concepts (open coding), extracting direct quotations as illustrations of these meaning units (axial coding, which obtains several segments of data), and derivation of themes (several codes grouped together) consistent or inconsistent with mindfulness theory.76 The PI gave each participant the opportunity to respond to the themes generated by their data, confirming accurate interpretation of the interview data and ensuring trustworthiness.70,77 To ensure that the final interpretations were embedded in the data, indicators of mindlessness and indicators of mindfulness were used to trace each theme back to significant statements from each interview transcription.76
Participant statements were consistent with all 8 indicators of mindlessness during prefailure and failure events. However, only 4 of 9 indicators of mindfulness were found postremediation and during repetition of the clinical course. Tables 1, 2, and 3 represent themes, sample quotes, mindful/mindless indicators, and generic abilities1/inabilities3 during pre-failure, failure, and post-failure, respectively. For example, during pre-failure, the statement “I ignored it” indicates that selfdeception is the mindless indicator and passivity is the generic inability.3
Table 1 represents pre-failure events during which participants demonstrated a lack of accurate self-assessment. Mindless indicators included ignoring, denial, and reactivity. Participants lacked presence by choosing to “excel” at something and remained outcome oriented. They admitted to viewing the clinical course as a goal that needed to be met, rather than as an opportunity to provide physical therapy to patients in need. The main theme of “Disconnect” emerged as participants ignored their thoughts and feelings, which created anxiety. As anxiety increased, the need to perform (“the harder I tried, the slower I got”) became maladaptive, as it was perhaps based on a fragile ego rather than a stable ego.58
Additionally, perfectionism created disconnection between participants and their CIs, and between participants and patients. Participants employed cognitive strategies rather than affective strategies to establish patient rapport, maintain professionalism, and engage in problem solving. The end result was a series of errors based on ignoring, perfectionism, and anxiety. Daniel stated:
I remember thinking, I am just a student, I can't do this! And the more I was expected to take over, the worse it (anxiety) got. We have their lives in our hands, and they could fall, they could fall if we are not absolutely on top of our skills, so it's scary. I was really scared, so I ignored it because I had never felt this way before. My classes did not prepare me for this…and I tried my best to prepare on my own, and make it up, but in the end it wasn't good enough.
Likewise, Tim stated, “I didn't see it coming. I kept hearing feedback about my confidence, but I didn't know what to do about it.” Janine stated, “I had never failed before, and I did not see it coming. I knew it did not feel right, but I didn't know what to do to fix it.” Shane stated, “I kept thinking, if I just work harder, come in early, stay late, they can't fail me. I worked so hard, and in the end, it didn't matter.” Oscar added, “I know now, looking back, that I exuded all that stress onto my patients…it affected everything I did. I know I am arrogant enough, every male physical therapist is arrogant. So I thought, just play the game.” Bee stated, “I had no idea that I would fail.” When probed with the question, “Was ego a part of this?” Bee stated, “Tremendously.”
During the first weeks of the clinical experience, participants consistently demonstrated mindless behaviors (ie, self-deception, covering up deficiencies, oversimplification, delusion for ego preservation), leading to failure in clinical education coursework. Participants responded to failure with emotionally biased evaluations of the self, which is consistent with previous studies that link disrupted emotion regulation to poor performance.40,51 Additionally, 4 participants continued to believe that they should not have failed. For example, Janine stated:
Well, my clinical was ‘in-patient’ and I didn't want to do in-patient. It's just not what I wanted to get into physical therapy for…but I didn't have any issues going into it….I was in ___ all alone. I didn't know anyone. I saw it as something I had to do, get it over with and I'll be done. I knew it would be terrible, and it was. I am a shy person, and don't like too many people to go to, like all the nurses! I had to ask about the status of the patient so I went around the unit looking at everyone's name tag…apparently that took too long (sarcasm) and I was told my time management was poor.
Table 2 represents the theme of “Failure as Nothingness,” when participants learned they had failed. In fact, 7 out of 8 participants stated that, if they could not be student physical therapists, then they were “nothing.” Several participant statements illustrated the rapid reaction and 1-dimensional problem solving that characterizes mindlessness.14,15 Participants appeared to approach the clinical setting in much the same way as they approached a multiple choice test in the classroom, using cognitive-evaluative criteria to solve affective domain problems. When these cognitive, left brain approaches did not address the problem, no other means existed to reduce the stress created by this uncertainty. This hindrance prevented them from responding with confidence.
Patient safety is a critical issue for CIs and DCEs.3 Two students in this sample felt that their CIs were exaggerating the impact of failing to lock wheelchair brakes during a patient transfer. From a CI's viewpoint, if a student does not consistently demonstrate safety, then safety is a threat to the patient. From the participant's viewpoint, the safety incident was an isolated action that would not have affected other patients. It contributed to the failure event because participants denied that the patient could have been harmed, which is consistent with mindless indicators of ego preservation and denial.
Table 3 represents the major theme of “Reconnect,” which occurred after remediation and repetition of the clinical course. All participants shared that failure felt sudden, personal, and based on external standards. The 8 participants stated that, after remediation, they each had a repeated clinical education experience that took place in similar clinical settings but with new CIs. Each participant learned that performance doesn't require perfection and that learning is life-long. This was a revelation to all participants, marking a moment in time when the evaluative nature of the clinical course ended and the more dynamic learning process began. In short, participants shifted from an outcome orientation to a more in-depth learning approach.
As students repeated their clinical courses, 6 participants developed a new awareness of their own thoughts and feelings. Tim, for example, stated that he was even more anxious in his repeat clinical, but soon realized that his new CI “truly cared” about him as a person, giving him the confidence to be open and ask questions. The CI reinforced that the clinic was a complex place that could not be mastered like a test in the classroom. The open connection between the student and CI encouraged a deeper learning process for 7 of the 8 participants.
Additionally, participants began to share feelings consistent with humility, which promoted mindful interactions with their patients. Five of the 8 participants began to integrate the emotional nature of the clinic and their own personal development. Asking questions, taking personal responsibility, and using self-talk were strategies that arose upon repetition of the clinical course. Five participants shifted thinking to a more patient-centered orientation. In all cases, as ego involvement and maladaptive perfectionism diminished, indicators of mindfulness (humility, lowered reactivity, naming, and openness) emerged.
Upon successful completion of the repeat clinical, participants shared indicators of mindfulness, with the exception of presence, self-compassion, and non-judgment. These may be the most valuable and meaningful tenants of mindful practice, yet they were not present in this sample.
One participant shared that she had visited a counselor. She stated:
Once I learned what I needed, it stopped being a guessing game, and I stopped acting aloof…like my breathing break became my umbrella…once you have an umbrella with you, it doesn't rain. I really got good at knowing myself after my year off.
Another participant shared his desire to focus on the patient. While this is a valuable shift, without the knowledge of mindfulness, the need for an internal self-focus was lost. Instead, this participant used self-blame and judgment to make sense of his failure. His focus remained on outcome orientation and a return to being “right” and “perfect.” He stated:
After I blamed everybody except myself, I started to read anything and everything I could get my hands on about the psychosocial aspect of patient care, and I learned so much more and had so many more wonderful experiences because of all this that I would not have had. I learned that I am a perfectionist, and I am hard on myself, like, I like to do things right and I doubt myself heavily when I feel like I am not perfect with all of my skills. I need to read and to take more courses so that I can get there.
Several participants shared that they would still struggle to ask their DCEs for help. For example, 1 participant stated:
If you ask for help, then you're in trouble. You get on the DCE's radar and there is no turning back. You almost become like a target, and your DCE sides with your CI. They (DCE) are not there, so of course they will side with them.
Another participant stated:
I still don't think about my feelings. I have a ‘that makes me angry’ side and a ‘that makes me happy’ side and a large ‘I don't give a shit’ in the middle, and a lot of stuff goes in there. I know I can do it. I just didn't do it her (CI) way. You gotta play the game.
This particular participant continued to lack a more in-depth approach to self-assessment. Terminology such as “emotion regulation,” “delusion,” and “reactivity” were foreign to him.
DISCUSSION AND CONCLUSION
Given the complexity and unpredictability of the clinical education setting,25 this study was the first to explore the meaning of failure for 8 PTs. In this sample, mindlessness was present before and during the failure events, and to some extent remained during and after remediation. Although several indicators of mindfulness arose after repetition of the clinical course, other important aspects of mindfulness, such as non-judgment and presence, were not identified. Altogether, these data suggest that mindful practice has the potential to prevent failure, offer healing after failure, or assist in remediation of deficits in clinical education courses.
CIs and DCEs can teach students the language of mindfulness by overtly discussing stress, including the internal barriers to accurate self-assessment. In this sample, the internal barriers of harsh self-judgment, fear, worry, and avoidance facilitated failure. For DCEs who often work with struggling students on the phone, through e-mail, or in person, several readily accessible strategies exist.
For example, 1 mindfulness strategy encourages the participant to stop/pause, take a breath, observe, and proceed with awareness (STOP).26 It is a quick method of tuning in to the body by focusing on the breath, thereby dampening the sympathetic response26 and allowing students to proceed with caution, action, patience, or a raised sense of awareness. It is not meant to examine, alter, improve, or fix the thought or emotion. It is simply to notice thoughts (“I am tired”) so that actions (“I will check the wheelchair brakes twice”) can prevent careless errors in patient care. As the pause becomes habitual, the breath becomes an easily accessible anchor for the student clinician.
An additional method similarly encourages participants to recognize, accept, investigate, and non-identify (RAIN).26 First, recognize the thought, feeling, or emotion. (“Here is worry.”) Accept it without judgment and with self-compassion, just as with a child or a dear friend. (“Everyone worries sometimes.”) Investigate where the body feels tight, hot, cold, numb, or tingly. (“I feel my shoulders tightening.”) Non-identify means to remain curious and objective about the thought or feeling rather than attached to personal assumptions and biases that typically unfold. (“I can breathe through this moment and remain present with my patient.”) Cultivating self-observance14,15,26 in the midst of everyday complexity makes the contents of the mind more manageable, as stressful events are seen as temporary.
Mindfulness training may also be formal, with guided meditation, body scan, narrative inquiry (written, oral, in pairs),13,21,78 and reading works from Kabat-Zinn,9,79 Epstein,10,11,14,15 Shapiro,22,42 Krasner,13 Chapman, 80 and Eva.28,33 A series of weekly activities can be layered as follows:14,21 (1) Focused awareness on the breath as an anchor during guided meditation of increasing length (5–30 minutes), (2) slowly eating a raisin with focused awareness of all the senses, (3) noting pleasant and unpleasant events in a daily calendar, (4) dialogue in pairs to develop listening skills, (5) narrative writing to develop awareness of actions and inactions, (6) sharing difficult conversations, (7) mindful movement (simple yoga), and (8) loving kindness meditation.14,69,78,80 When students let go of judgment, become curious of their emotions, thoughts, and body sensations, and cultivate well-being through presence,9,69,79–81 the impact on clinical education and patient care can be substantial.
The sample size used in this study was consistent with previous phenomenological studies in physical therapy and data saturation was achieved.70–72 In hindsight, a mixed methodology could have been more inclusive and perhaps more telling of all students engaged in clinical education.76 Although a variety of validated mindfulness surveys exist, this type of methodology was dismissed because each has disregarded significant functions of mindfulness, such as labeling, emotion regulation, and stillness.37
Additionally, the nature and type of remediation was not clearly identified by the participants, although each stated that they were told to reflect on what they had done wrong and to do readings and write papers for their DCEs. They each discounted this phase of their journey and the PI chose not to explore these details within this study. Clearly, remediation is a unique, individualized process that is worthy of investigation.
Peer checking was not employed as is typical of phenomenological research.70,71 Although member checking using participant feedback was attempted, only 3 of 8 participants confirmed thematic representation based on their interview statements. Finally, participants reflected back on their thoughts and feelings at the time of failure, which could mean that participants simply gained maturity over time.
Adding mindful practice to the physical therapy curriculum may benefit at-risk students early in their clinical training60 while offering faculty members an evidence-based means to offer support and healing. Students who practice mindfulness may be better prepared to identify and stay present with stressful thoughts and feelings, respond to these with non-attachment and non-judgment, demonstrate more flexibility of thought (shifting from “doing” mode to “being” mode and back again), be open to creative solutions, respond rather than react, and have improved mood, empathy, and well-being.11,14,16,18,37,52,78,79,82–84 The benefits of mindful practice have applicability for written exams, lab work, practical exams, integrated clinical experiences, simulated experiences, in-service training, service-learning, and problem-based learning.
It is recommended that mindful practice be added to the American Physical Therapy Association's (APTA) CI Credentialing Course85 and to materials that CIs obtain from individual programs. For example, the clinical education manual offers 1 venue to disperse information to students, CIs, and CCCEs regarding stress management using this evidence-based strategy. Students and CIs may act as mindfulness ambassadors to teach patients and other professionals about self-care, self-compassion, and non-judgment to decrease the effects of stress on the body and mind.
Future research may explore how DCEs/CIs can assist and support students with mindless behaviors. Research questions may appear in this manner: (1) How can CIs offer non-threatening feedback that encourages students to enact behavioral change? (2) Does adding a formal mindfulness curriculum create success in generic abilities? (3) Does remediation using mindfulness theory and practice create success in generic abilities? (4) Does regular written narrative during clinical education facilitate mindfulness?
Our deepest gratitude goes to the physical therapists for courageously sharing their stories with us. Gratitude to Dr Ernest Nalette who asked, “Have you heard of mindfulness?” Thank you to Dr Terri Hoppenrath for presence and to Dr Kathleen Buccieri for wisdom.
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Appendix A: Indicators of Mindlessness10–12,16
Appendix B: Indicators of Mindfulness10
Appendix C: The Interview Guide