Mindfulness: Applications 1

MINDFULNESS: APPLICATIONS FOR ETHICS EDUCATION

Mindfulness: Applications for Teaching and Learning In Ethics Education Gail M. Jensen Creighton University Medical Center

1

Mindfulness: Applications 2 Author Page

Gail M. Jensen, PhD, PT Associate Dean for Faculty Development and Assessment Professor of Physical Therapy School of Pharmacy and Health Professions Creighton University Medical Center 2500 California Plaza Omaha, NE 68178 (402) 280-3727 (402) 280-1268 FAX [email protected]

2

Mindfulness: Applications 3

One day, at a nursing home in Connecticut, elderly residents were each given a choice of houseplants to care and were asked to make a number of small decisions about their daily routines. A year and one half later, not only were these people more cheerful, active and alert than a similar group in the same institution who were not given these choices and responsibilities, but more of them were still alive. In fact, less than half as many of the decision-making, plant-minded residents had died as had those in the other group (Langer, 1989).

The startling results of this experiment done in the 1980s led Dr. Ellen Langer and her colleagues into research on what they call “mindfulness.”

3

Mindfulness: Applications 4

Mindfulness: Applications for Teaching and Learning In Ethics Education

Mindfulness is an ancient Buddhist practice that has to do with being in touch with our present-day lives (Kabat-Zinn, 1994). Mindfulness is a flexible state of conscious awareness characterized by being engaged in the present moment noticing new things, novelty and being sensitive to context and perspective(Langer, 1989). When we approach something that we believe we know well then we tend to view it mindlessly however when we approach something that is novel to us we approach it mindfully.

In 1999, Dr. Ronald Epstein (Epstein, 1999) published an article in JAMA on mindful practice that has caused continued discussion among medical educators about the role of mindfulness in the development of professional competence (Epstein & Hundert, 2002; Leach, 2002). Epstein (Epstein, 1999) argues that mindfulness is a natural extension of reflective practice. Furthermore. he believes that the process of critical selfreflection that is seen in exemplary or expert practice depends on the presence of mindfulness. Mindfulness means paying attention in a particular way, in the present moment and being nonjudgmental (Langer, 1989). A mindful practitioner attends in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables the practitioner to fully listen to the patient, self-monitor, bring multiple sources of knowledge and deeply held values to both ordinary and complex situations (Epstein, 1999; Eraut, 1994).

4

Mindfulness: Applications 5 The concept of mindfulness appears to have many similarities with how we describe expertise. We have evidence across the health professions that expert clinicians attend to patients in a nonjudgmental way, engage in moment-to moment self-monitoring, rely on practical wisdom gained through experience, and use their senses and awareness to acquire new information. Their ability to make clinical judgments draws from many sources of evidence, yet centers on understanding the perspective and context of the patient and family/care giver situation (Benner, 1984; Benner, Tanner, & Chelsa, 1996; Higgs & Tichen, 2001; Jensen, Gwyer, Hack, & Shepard, 1999).

As an educator teaching health professions students ethics, I continue to struggle with the question - How do I best prepare students who will enter the profession as novices, yet have the ability and necessary moral foundation to develop expertise? Course content in ethics and other areas of the behavioral sciences are often seen by students to be in stark contrast to the intensity of the basic and clinical sciences. While there is acknowledgment that ethics is needed given the current pressures in health care, the reality of professional curricula remains. Students learn quickly the lessons of the explicit and implicit curriculum – there is strong emphasis on the “hard sciences” where the need to memorize and digest extensive amounts of content in order to survive is seen in stark contrast to the more experiential, theoretical and applied emphasis in the behavioral sciences (Kopelman, 1999; Shepard & Jensen, 1997). While many health professions educators have embraced Schon’s (Schon, 1987) concept of reflective practice as a central component of professional competence (Eraut, 1994; Higgs & Tichen, 2001) there has been far less discussion and exploration of what elements may underlie critical self-reflection and mindfulness.

5

Mindfulness: Applications 6 Dewey (Dewey, 1916) argued that “the object and reward of learning is continued capacity for growth and that students develop skills and habits of mind that will enhance their creativity and problem solving abilities with respect to the issues they are likely to meet. “The tools of ethics include developing “habits of mind” for reflection on complex, changing situations that are part of everyday practice. Facilitating reflective habits of the mind is a necessary, but difficult challenge in a professional education environment (Barnitt & Roberts, 2001; Jensen & Paschal, 2001).

Ethics educators in occupational therapy and physical therapy, as an organized community of concern, serve a potentially critical role in facilitating necessary changes in education that lead to integration of “habits of mind” as essential elements of professional competence. The concept of mindfulness as a “habit of mind” is worthy of dialogue. The purpose of this paper is to explore the concept and practice of mindfulness as applied to teaching and learning of ethics.

Understanding Mindfulness

Mindfulness is a practice that stems from a philosophical-religious tradition where the underlying philosophy is pragmatic. The practice of mindfulness is based on the interdependence of action, cognition, memory and emotion (Langer, 1989, 1997). Mindfulness is a quality of a person or practitioner that does not place boundaries between cognitive, technical, emotional and spiritual aspects of practice. Epstein (Epstein, 1999) says “Mindful practitioners have an ability to observe the observed while observing the observer in the consulting room.” (p835) The goals of mindful practice

6

Mindfulness: Applications 7 are to be more aware of one’ s own mental processes, listen more attentively, be more flexible, recognize bias and judgments and act with principles and compassion. (Table 1)

Epstein (Epstein, 1999) suggests that mindful practice is a logical extension of reflective practice. When practitioners are mindful, they are able to engage in critical self-reflection. What makes reflection critical? Brookfield would argue this – “Critical reflection on experience certainly tends to lead to the uncovering or paradigmatic, structuring assumptions…For something to count as an example of critical reflection, I believe that persons concerned must engage in some sort of power analysis of the situation or context in which the learning is happening.” (Brookfield, 2000), p. 126) Critical self-reflection depends on the ability monitor own progress also referred to as meta-cognition or meta-processing (Mezirow & and Associates, 2000). The process of meta-processing begins with intrapersonal self-awareness (Mentkowski & and Associates, 2000; Mezirow & and Associates, 2000). This insight into self allows the practitioner to see themselves as they are seen by others and helps establish satisfactory interpersonal relationships. In turn, this self-awareness helps the practitioner transcend and see connections across all areas of practice (e.g., technical, cognitive, emotional, spiritual) versus separation. Mindfulness allows the practitioner to “welcome uncertainty” and see difficult or problem patients as areas for creative problem solving versus unsolvable problems (Epstein, 1999; Langer, 1997).

Mindfulness also facilitates “connected knowing” as knowledge is not seen independently but in relationship to the one observing and using that knowledge (Blensky & Stanton, 2000). Tacit knowledge, that knowledge that is learned through observation

7

Mindfulness: Applications 8 and critical reflection on practice is another source of evidence for clinical judgment and decision making (Epstein, 1999; Eraut, 1994). The object of mindfulness applies to any and all domains of knowledge whether explicit or tacit (Demick, 2000; Langer, 1989).

Langer (Langer, 1989) has a chapter in her book on Mindfulness entitled, “when the light is on and nobody is home.” This is an example of what she refers to as mindlessness. She describes mindlessness as acting automatically according to our behavior made in the past rather than in the present (Langer, 2000). She suggests that these three descriptions can help us further understand the concept of mindlessness; 1) experiencing the world when we are trapped by categories and make distinctions based on those categories, 2) automatic behavior, and 3) acting from a single perspective as if there were only one set of rules (Langer, 2000). Furthermore, she believes that education has a great deal to do with fostering mindlessness when it is focused on learning the facts and getting the right answer – done without attention to the perspective or context of the situation (Langer, 1997).

What are the consequences of mindlessness in clinical practice situations? Epstein (Epstein, 1999) points out that when mindlessness occurs in medicine, one sees gaps between knowledge, values and actions.

Physicians make moment-to-moment value laden decisions that entail cognitive and emotional factors…These rapid decisions based on personal knowledge, level of skill, efficiency, and values ultimately result in actions….Self knowledge is essential to the expression of core values in medicine such as empathy, compassion and altruism. (p. 836) For example, for a clinician to be empathic she must be present – understand the patient’s suffering as well as be able to distinguish the patient’s experience from her own.

8

Mindfulness: Applications 9 It may be a lack of self-awareness on the part of the clinician that contributes to confusion of own perspective with the patient’s and leads to less patient-centered care (Stern, 1998). In situations of uncertainty and emotional charge, mindlessness can contribute to deviations from professionalism such as avoidance of difficult situations, externalization, or denial (Feudtner, Christakis, & Christakis, 1994).

Mindful Practice: What does it look like?

Epstein (Epstein, 1999) proposes a model that outlines the five levels of mindful practice. While the model has not yet been verified with research, it poses a useful tool for thinking about what we might see in clinical practice settings. The five levels are as follows:

Level 0 - Denial and Externalization. At the extreme level of mindlessness we would see practitioners demonstrate denial and externalization. The problem is out there with the patient. This allows the practitioner to avoid taking responsibility for the situation. “Not his problem, but the problem is centered elsewhere.”

Level 1 – Imitation: Behavior Modeling. At level 1, while practitioners may not necessarily engage in reflection, they will take some responsibility for the situation and attempt to solve it by conforming to some external standard of behavior. For example, a therapist may have a patient who is not following the procedures for his work hardening program. The therapist decides to call the case worker and make the patient aware the proper guidelines, but does no further probing to find out what may be underlying the patient’s behavior.

9

Mindfulness: Applications 10 Level 2 - Curiosity: Cognitive understanding. Here the practitioner does engage in some reflection triggered by curiosity, he makes his decision based on explicit cognitive models and focuses on the transfer of information. In doing this, he ignores personal knowledge, tacit knowledge, and emotions. For many of us in physical therapy, as an emerging profession, this is perhaps where there is the greatest amount of emphasis and energy in our efforts to claim evidence in support of our practice. We focus on the critical importance of the “knowledge” – making the “diagnosis” and proving ourselves to the patient with transfer of a large amount of information.

Level 3 – Curiosity: Emotions and attitudes. At level 3, the practitioner is open to and includes thoughts, feelings, and behaviors without judging as good or bad. This inclusion of personal knowledge and emotions provides the practitioner with additional tools for patient-centered care.

Level 4 – Insight. This level includes 3 components of practitioner understanding: the nature of the problem, how one attempts to solve it, and the interconnectedness between the practitioner and the knowledge she has.

Level 5 – Generalization, incorporation and presence. At this level, the practitioner uses their insight to generalize, incorporate new behaviors and attitudes, overcome similar challenges in the future, express compassion and be present.

How might these levels of mindfulness be applied to examples of clinical cases? Here are two contrasting clinical case examples – one representing an example of mindless practice and a second case as an example of mindful practice. Both of these

10

Mindfulness: Applications 11 cases have been generated by doctor of physical therapy (DPT) students. One from an entry level student and the second from an experienced therapist in the transitional DPT program. Both case vignettes are shared with permission.

The Case of Sally, John and Maria

Sally is a physical therapy student on her second three week clinical affiliation. She is assigned to a local county hospital that provides free health care to the community. Sally’s clinical instructor, John, has been in practice for over 15 years. Maria is a 69 year old patient who recently received a total hip replacement. She speaks no English and has no family in the area. John has been treating Maria for one week prior to Sally’s arrival. On this day John briefs Sally and asks if she speaks any Spanish. John goes on to say that Maria speaks no English and he is having trouble communicating with her. Upon Maria’s arrival, Sally sits back and watches John treat her. She sees that there is no communication between the therapist and the patient. Maria’s care included manually resisted hip flexion, knee extension and ambulating 30 feet twice with a front wheeled walker. Sally sees that Maria is bending over significantly to get out of her wheelchair and that John is extremely frustrated at how the treatment is progressing. Maria seems to be taking no active role in the therapy and treating is a chore. After Maria leaves, Sally asks John if Maria has received any patient education as to hip protocols, transfers, or the plan of care and goals. John states that since he knows no Spanish he was unable to give the amount of education he thought was necessary. Sally asks if thought of using a translator to which John said there were none employed by the hospital. John also states that Maria will be transferring to a local nursing home in the Latino area of town where she will get proper education. One day a young man who spoke Spanish happened to bring Maria to the treatment room and Sally knew this was her chance. Without consulting John, she got the young man to translate the hip protocol for her. At the end of the session, Maria said she was thankful as before she had no idea what was going on and what she needed to do. John, the clinical instructor and licensed physical therapist in this case, appears to be at mindfulness - level 0, denial and externalization. He sees that the language barrier with his patient is her problem, not his. Even though he is aware of his frustration, he does nothing to address it other than ask his student if he knows Spanish. His ultimate

11

Mindfulness: Applications 12 solution is to rationalize this case in his own mind and see that the patient will get “patient education” when she returns to her community.

The student writing this ethics

case, appears to be at level 3 as he uses his curiosity that includes his feelings and emotions about what he was observing in this clinical instructor. In this second case, we have an experienced therapist who used this ethics case writing assignment as an opportunity to reflect back on a powerful clinical exemplar. Reflections on Blessings I have thought long and hard about this case for quite some time. As is frequently the case in practice, we make decisions based upon our instincts and the available facts only to later reflect and question whether those decisions were truly right. Case in point, I had been called to a meeting of several important Rabbis from the Lubovich sect, one of the Hassidic Dynasties located in Brooklyn. The chief Rabi known as The Rebbe had suffered a major stroke, and they wanted to interview me about possibly doing homecare on this case. Not being Jewish, I didn’t fully appreciate the importance of The Rebbe. He was truly an international leader; many of his followers actually thought of him as the Moshiach, the savior. In fact, even though he has been dead for a long time, many of his followers still believe he will return and reveal himself as such. Needless to say, this was an extensive interview process, which culminated in my being hired to work on this man. He was housed in his office where a hospital room had been set-up. There was always a male nurse with him and always at least two Rabbis to pray with him. I was rather intimidated by the whole scene at first, but quickly had established a good working relationship with The Rebbe and our sessions were progressing. The Rebbe was a man who was not used to having anybody say the word “no” to him. He simply got whatever he wanted, no questions asked. Therefore prior to each session, I was instructed to ask him if we could proceed with the PT session. During the early sessions, there was considerable pressure on me to get The Rebbe walking as soon as possible so that he could lead the congregation in prayer. All went well for a few weeks until one day when he refused PT. He would occasionally do that, and I would usually wait for a while and try again. Almost always we would then proceed with the session. On this day, however, it was not to be. He refused for several days in a row, making the people in charge rather anxious. I was not able to motivate him to participate in PT at all. It rather appeared to me that he had given up all hope and was just waiting to expire. At this point one of

12

Mindfulness: Applications 13 the Rabbis gave me some advice. He told me to ask The Rebbe for his blessing that my work with him would be a success. He reasoned that if The Rebbe gave me that blessing then he would have to consent to PT in order for the blessing to come true. This was the start of my Ethical Distress, although I didn’t call it that at the time. I had no belief in his blessing, and he was smart and intact enough to know that. Should I lie to the patient to motivate him to agree to PT? I had several duties at that time. First, I had a duty to my patient to provide him with sound physical therapy treatment. Part of that is the ability to motivate patients to perform when they may not be willing to do so. I also had a duty to the physician and the Rabbis who had put their faith in my ability to help them with this case. I felt a sense of duty to the whole congregation who would all gather each evening for prayer hoping that The Rebbe would lead them. On top of this, I had a duty to be honest with my patient and to respect his autonomy. However the guiding theory for me at that time, although I didn’t know it, was an ethic of care. I had reached a point in our relationship where I truly cared for this man. I knew that his past glories would never be repeated, but if he could walk to his balcony and lead his congregation in prayer, he would benefit greatly. I knew that his fear of failure was the limiting factor, and I believed that he had let me get close enough to him to make a difference. I approached The Rebbe and made eye contact. I quietly told him how much I wanted our work together to succeed. I asked him for his blessing that our work would be successful. He looked at me for a long hard moment which I shall never forget, then nodded and said something in Hebrew. After a few moments we started our treatment session. Several of the Rabbis in the room were stunned. They thought I had tried to trick him into agreeing to cooperation, but when he began to participate in PT, nothing was said. The Rebbe never refused a treatment again after that day. He progressed in his PT rather well. Shortly after the event, he did begin going to his balcony in the evenings and led the congregation in prayer. I am still held in high-esteem by the people of that community for my work with their religious leader. However, I know that when he looked into my eyes he knew very well what I was trying to do, but he allowed me to get away with it. Perhaps in the final analysis he did maintain his autonomy. He could have easily ignored me or had me released from the case. The caring relationship we had built over time had paid off.

In this case, the therapist demonstrates sound evidence of mindfulness, perhaps at Epstein’s highest level – presence. His critical self-reflection allowed him to examine

13

Mindfulness: Applications 14 his own belief system and values, while still being present and nonjudgmental with his patient. As I reflect on both of these cases and ask myself – what contributed to the students’ ability to demonstrate mindfulness? While they used the structure of the learning experience and written clinical ethics case report as an opportunity to think back about their thinking and actions in these cases, there is evidence of mindfulness in their actions. For the Sally – perhaps it was because she was initially the “observer of the observed” as she was the student watching the therapist and the patient and from a minority group herself. For the experienced therapist, it may have been that his initial handling of the case came from his tacit knowledge and intuitive decision making. Now he was using this learning experience as an opportunity to critically self-reflect on his actions.

Mindfulness: Does it have a role in teaching and learning in ethics?

“The greatest gift that faculty can give to students, and that they can give to themselves is to infuse all they know with a healthy uncertainty.” (Langer, p. 2) We all know first hand the delight with which health professions students engage in ethics when they suddenly realize that uncertainty is more prevalent than right answers. Here is a quote from one of my student evaluations on his self-assessment:

At the beginning of this semester I was not excited about taking this course. I hated classes like this. I also was not fond of your teaching style. Your lectures were all over the place and seemed meaningless. Sound familiar? (good thing I am tenured…). I believe that facilitating the development of mindfulness in our students as both a formative and summative outcome of professional competence has everything to do with

14

Mindfulness: Applications 15 teaching and learning in ethics. In fact, as I critically reflect on what we know about student learning – ethics may be the most ideal component of the professional curriculum for facilitating true mindful learning.

Now that I have said this – I am not sure how pieces of the puzzle of mindfulness fit together. Let me share my continual struggle with this paper - I keep asking myself – it seems like there several core constructs the underlie “mindfulness” are directly related to our ultimate goal in health professions education – preparing a competent health practitioner who will engage in life long learning and continue to develop expertise. Epstein and Hundert (Epstein & Hundert, 2002) define professional competence as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served. Furthermore they state that competence in medicine is built on a foundation of basic clinical skills, scientific knowledge and moral development. Essential to this building of competence is habits of mind – including several of the characteristics of mindfulness – attentiveness, critical curiosity, selfawareness and presence.

If I look more closely at several of the terms used in discussing mindfulness I see concepts that do not appears to be mutually exclusive but are being used in ways to bring more clarity to the concept or perhaps are being seen through a different disciplinary lens. For example, John Dewey’s (Dewey, 1916) notion of inquiry is a central tenet of reflection. One cannot reflect or engage in inquiry unless he or she is aware of context – that is something different or problematic. Critical self-reflection involves thinking about

15

Mindfulness: Applications 16 one’s own learning (Mentkowski & and Associates, 2000; Mezirow & and Associates, 2000) and to do that one must be mindful (Epstein, 1999). Brookfield (Brookfield, 1995) emphasizes that there are three common assumptions for critical reflection – paradigmatic assumptions that structure the world into categories with the most difficult to identify being in oneself, prescriptive assumptions about what we think ought to happen in a specific situation, and casual assumptions about how the world works and how it may be changed. Transformation of learning occurs when there has been movement and a reformulated structure of meaning (Mentkowski & and Associates, 2000; Mezirow & and Associates, 2000) Mentkowski and colleagues (Mentkowski & and Associates, 2000) would argue that transformative learning occurs when learners have engaged in four domains of growth – development and self-reflection, reasoning and performance. In this transformative learning model the critical elements for learners include using metacognitive strategies (thinking about their thinking); self-assessment of performance and awareness of context. Doesn’t this sound like mindfulness? It seems like I have just gone around in a circle.

What I can share with some confidence is evidence from my inquiry into student learning in my ethics teaching (Jensen, April 21, 2003). My teaching of ethics continues to evolve and be shaped through mentorship of my colleagues at the Center for Health Policy and Ethics. The past two years, I have continued to integrate more active learning experiences into the course and go beyond case analysis to use of standardized patients and student analysis and reflections on those interactions. Here is a description of the initial standardized patient case experience and examples of data from initial analysis of student responses to this first experience.

16

Mindfulness: Applications 17 The first SP case presents a very common dilemma for physical therapists, honoring patient autonomy when it may be in direct tension with promoting beneficence or good for the patient. One of key elements in the case centers on the issue of patient adherence or ability to follow through with exercise programs and safety concerns. One of the challenges for therapists is being present, respecting the patient, yet listening to the concerns of the patient and family, while working together toward a mutually acceptable solution. Students responded to the following questions immediately following their interaction with the standardized patient:

1. 2. 3. 4. 5.

What was the CENTRAL ethical issue you encountered? At the end of the interview, why did you choose the action you did? If you were the therapist in this case – what would you DO NEXT? What still confuses you about this case? What did you LEARN about YOURSELF from doing this encounter? (what can you do now that perhaps you can do now?)

When I analyzed this narrative data, I found the following: student responses and reflections centered around issues of uncertainty and self-confidence. The specific coding categories for student responses and reflections were: 1) Struggle, frustration, problem focus, personal insight; 2) Struggle, personal insight, respect for the patient, and 3) No struggle, confident, knows the solution.

Struggle – frustration -- problem focus -- personal insight. The majority of student responses were in the category of the student struggle, frustration, problem focus, and personal insight. Here students acknowledge the struggle and uncertainty of the interaction with the “stranger,” that is followed by their expressions of some frustration with their inability to “fix the problem” and then a reflective focus on self and need to improve their skills. Here is an example of this approach from Kate:

17

Mindfulness: Applications 18 Kate: The problem in this case was that the patient did not want to go to a nursing home yet she could not do her ADLs….she was non-compliant…..I really wanted to try to provide the patient with independence and give her an ultimate last chance but it didn’t work. I feel I am getting better at trying to understand the patient’s needs.. I need to look at the bigger picture.

Struggle -- personal insight -- respect for the patient. A smaller cohort of students (n=7) had evidence of recognizing the struggle and uncertainty of the case along with personal insight and then an ability to bring that insight together with ethical principles as seen here with Don.

Don: Patient autonomy was the central issue in this case. Also as a PT I did not want to do harm to the patient or the family and wanted to help them. At first, I was going off of what the family was saying was true but then it might not mean that the patient wasn’t telling the truth but maybe there was a lack of communication. I had to think on my feet and I learned to give the patient the benefit of the doubt and try to think of how we could get to the underlying problem. I feel like I was able to maintain respect for the patient. No struggle – confident -- knows the solution/judgmental. Another small cohort of students (n=8) experienced no reported struggle, was not confused about the case at all, and were very confident in their ability to resolve the based on their judgment of what needed to be done.

Chris: The patient had desires that were in direct conflict with her overall well being and health status… I simply told the patient that we were going on with the family conference where we could hear the concerns of all involved. I learned that I can deal with an ethical issue on the fly and do that without stumbling over my words or thoughts. Although I have spent the last 15 years priding myself in the role of advocate for promoting methods of facilitating reflection in my students, this inquiry into my teaching through evidence of student learning became a critical incident for me. I will never

18

Mindfulness: Applications 19 forget that moment of my own personal insight as I realized that I had a deeper understanding of what students were actually thinking. For the students, I believe the standardized patient interaction provides a more realistic, authentic learning experience that mirrors clinical reality. For physical therapy students, I believe this kind of experience enhances the clinical credibility of ethics. The experience also places a different emphasis on ethical case analysis that goes beyond analysis of a paper case or discussion of media clip. Students in the standardized patient experience are at the center of the action/interaction as part of a “lived experience.” The structured de-briefing questions students responded to immediately after the interaction, appears to facilitate further student reflection on the SP process and provided me with insight into their reflective process. As I continue to think about this learning experience in the context of this paper, I see evidence of mindful learning. Perhaps standardized patient interactions provide an authentic performance-based learning experience is more consistent with what Langer calls – sideways learning (Langer, 1997). She contrasts sideways learning with the standard top-down (traditional lecture) or bottom-up (direct experience and repeated practice) approaches that dominate most educational settings. Sideways learning revolves around facilitating a mindful state where there are the following characteristics: “1) openness to novelty, 2) alertness to distinction, 3) sensitivity to different contexts, 4) implicit, if not explicit, awareness of multiple perspectives; and 5) orientation to the present.” (p.23) For those students who were very confident about their ability to fix this problem” and not confused about the case at all – there was little sense of context or perspective –

19

Mindfulness: Applications 20 only their own. For the other two groups of students – the struggle with the uncertainty led to some frustration which in turn led to some evidence of critical self-reflection. Remember the quote from the student who hated classes like this that began this section of the paper – well here is the remainder of his self-assessment. This is a young man, who in his first standardized patient interaction was very confident and told the patient she had better exercise or go to the nursing home. I took the opportunity to reflect on his reflections of how he handled the patient interaction with a few gentle insights. This led to an observable change. He started sitting up front in class and actively participating in class. Here is what he wrote in the remainder of his self-assessment at the end of the course. Solving ethical issues is still the hard part. My background is in science at the cellular level where I look for a certain right or wrong answer. Over the course of the semester I have learned that in many cases there is not a certain right or wrong answer and answers seem to lead to more questions. However, many times that may be the best answer. (Then in his comments on the back of the page) .. I did not see ethical problems in your examples. At this point, I was wrong about everything and I am not afraid to admit it. I have learned so much, not about the cases but about myself much of this I cannot explain in words. Your class has changed the way I look at many situations and this is for the better… So is this Evidence of Mindful Learning?

I started this section with the comment that I believe ethics education may be the most ideal component of the professional curriculum for facilitating true mindful learning. I still believe that. I will close the paper with a quote about “a table of learning” from Lee Shulman (Shulman, 2002). For me this paragraph embodies key elements in teaching and learning in ethics.

20

Mindfulness: Applications 21 Learning begins with student engagement, which in turn leads to knowledge and understanding. Once someone understands, he or she becomes capable of performance or action. Critical reflection on one’ s practice and understanding lead to higher order thinking in the form of a capacity to exercise judgment in the face of uncertainty and to create designs in the presence of constraints and unpredictability. Ultimately, the exercise of judgment makes possible the development of commitment. In commitment, we become capable of professing our understandings and our values, our faith and our love, our skepticism and our doubts, internalizing those attributes and making them integral to our identities. These commitments, in turn, make new engagements possible – even necessary. (Shulman, 2002 p. 38 ) As ethics educators in occupational therapy and physical therapy and an organized community of concern, we serve a critical role in facilitating necessary changes in health professions education. What will we do?

21

Mindfulness: Applications 22 References

Barnitt, R., & Roberts, L. (2001). Facilitating ethical reasoning in student physical therapy. Journal of Physical Therapy Education, 14(3), 42-47. Benner, P. (1984). From Novice to Expert. Menlo Park, CA: Addison-Wesley. Benner, P., Tanner, C. A., & Chelsa, C. A. (1996). Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York, NY: Springer Publishing Co. Blensky, M., & Stanton, A. (2000). Inequality, development and connected knowing. In J. Merizow (Ed.), Learning as Transformation. (pp. 71-102). Brookfield, S. (1995). Becoming a Critically Reflective Teacher. San Francisco: JosseyBass. Brookfield, S. (2000). Transformative learning as ideology critique. In J. Merizow (Ed.), Learning as Transformation (pp. 125-150). Demick, J. (2000). Toward a mindful psychological science: theory and application. J of Social Issues, 56(1), 141-159. Dewey, J. (1916). Democracy and Education. New York: Macmillan Publishing. Epstein, R. (1999). Mindful practice. Journal of the American Medical Association, 282, 833-839. Epstein, R., & Hundert, E. (2002). Defining and assessing professional competence. Journal of the American Medical Association, 287(2), 226-235. Eraut, M. (1994). Developing Professional Knowledge and Competence. London: Falmer Press.

22

Mindfulness: Applications 23 Feudtner, C., Christakis, D. A., & Christakis, N. A. (1994). Do clinical clerks suffer ethical erosion: student perceptions of their ethical environmental personal development. Academic Medicine, 69, 670-679. Higgs, J., & Tichen, A. (2001). Practice Knowledge and Expertise in the Health Professions. Boston, MA: Butterworth-Heinemann. Jensen, G. M. (April 21, 2003). Exploration of critical self-reflection in the teaching of ethics: the case of physical therapy. Paper presented at the American Educational Research Association Meeting., Chicago, IL. Jensen, G. M., Gwyer, J., Hack, L. M., & Shepard, K. F. (1999). Expertise in Physical Therapy Practice. Boston, MA: Butterworth-Heinemann Publishers. Jensen, G. M., & Paschal, K. (2001). Habits of the mind: student transition toward virtuous practice. Journal of Physical Therapy Education, 14(3), 42-47. Kabat-Zinn, J. (1994). Wherever you go there you are. New York: Hyperion. Kopelman, L. (1999). Values and virtues: how should they be taught? Academic Medicine, 74(4), 1307-1310. Langer, E. J. (1989). Mindfulness. Cambridge, MA: Perseus Books. Langer, E. J. (1997). The Power of Mindful Learning. Reading, MA: Addison-Wesley. Langer, E. J. (2000). Mindful learning. Current Directions in Psychological Science., 9(6), 220-223. Leach, D. (2002). Competence is habit. Journal of the American Medical Association, 287, 243-244.

23

Mindfulness: Applications 24 Mentkowski, M., & and Associates. (2000). Learning that Lasts: Integrating Learning, Development and Performance in College and Beyond. San Francisco: JosseyBass Publishers. Mezirow, J., & and Associates. (2000). Learning as Transformation. San Francisco, CA: Jossey-Bass Publishers. Schon, D. (1987). Educating the Reflective Practitioner. San Francisco: Jossey-Bass Publishers. Shepard, K. F., & Jensen, G. M. (1997). Handbook for Teaching for Physical Therapists. Boston, MA: Butterworth-Heinemann Publishers. Shulman, L. (2002). Making differences. Change, 34(6), 36-44. Stern, D. T. (1998). Practicing what we preach? An analysis of the curriculum of values in medical education. American Journal of Medicine, 104, 569-575.

24

Mindfulness: Applications 25 Table 1. Suggested elements of mindful practice (Epstein, 1999) ______________________________________________________________ Active observation of oneself, patient and the problem(s) Peripheral vision Preattentive processing Critical curiosity Courage to see the world as it is rather than as one would have it be Willingness to examine and set aside categories and prejudices Adoption of a beginner’s mind Humility to tolerate awareness of one’s areas of incompetence Connection between the knower and the known Compassion based on insight Presence __________________________________________________________

25