A 67 year old patient presented to the ward during my neuro placement. This patient had the formal diagnosis of Motor Neurones Disease (MND) for two weeks, but had noticed rapid onset of symptoms since Christmas of the previous year. As you would be aware, MND is a progressive neurological disorder that destroys motor neurones, resulting in symptoms such as weakness and muscle wasting, fasciculations, spasticity/rigidity, overactive reflexes, and eventual death. As cognition remains intact, this prognosis would conjure many emotional issues, for both the patient and their family. Even I could not help but feel saddened for this lovely patient, as in a few months, they had moved from being a healthy, talkative, independent individual to someone that was unable to verbalise (now used a lightwriter) and required assistance in all aspects of daily life.
This patient was always compliant and willing to participate in physiotherapy, with maintenance of functional mobility being our joint focus. One morning I had wheeled this patient to the physiotherapy gym, aiming to practice sit to stand and bed mobility. Everything seemed to be going well- I was happy, the patient appeared happy and the exercises were progressing well. All of a sudden, the patient began to cry, with this cry quickly becoming a wail. I drew the curtains around the plinth, as not to disturb other patients. When asked what was wrong, the patient would not answer so I just held her hand and reassured that we would finish and return to her room. She seemed happy with this, and the tears soon stopped.
As I began to wheel her back to her room, she began to cry again, and appeared more visibly upset than before. So I stopped and sat down with the patient in the hallway. It really broke my heart to see someone so upset. As I asked again what was wrong, the patient began to inform me that they felt so helpless. They had deteriorated so quickly, and felt there was nothing that could be done to help. I found it really difficult to know what to say. I knew I couldn’t tell her “it will be ok” or “I’ll help you to get better”. We both knew she did not have many months to live. I struggled to hold back tears as I sat there with the patient, resting my hand on theirs. All I could say was “I’m sorry” and say that I was there to listen and help as much as I could.
It is really difficult to know how to handle these situations, and there is definitely no set recipe. I believe that as physios, especially as students, we become so focused on fixing and treating the problems, that we can forget the patient. It really doesn’t take much time from your day to stop and say to a patient “How are you really going?”; and if they ever begin to cry, all you can really do is try to find a quiet place, and lend a listening ear. Obviously, I didn’t get much treatment accomplished during the session, but I believe that the patient communicating with me was of much more benefit. These emotional issues can then be communicated to other appropriate health professionals.
It’s so easy to take life and our own health for granted, that we don’t always stop and think of the struggles that our patients must be facing. So try to take time during the day to think of how your patient may be feeling, as I think this will help you to develop a more holistic understanding and empathetic attitude towards the person. I know I will be.
Monday, May 26, 2008
A patient with expressive aphasia expressing herself by crying and cursing
I am currently on a neurology placement and one of my patients suffered a (L) stroke 4 weeks ago which left her with right hemiplegia. She has good static and dynamic sitting balance and reasonable static standing balance with 2 x moderate assistance. Her right upper and lower limb are both gowland stage 3 of recovery. She also has expressive aphasia which she finds very distressing. As she was still a two person transfer to plinth (and it was only our first week of the placement) I saw her with another student. Her previous physio informed us that she had been working on sit to stand for about a week so we could continue to improve her perfomance of this task and progress her work in standing.
The first session did not get off to a good start. Even before the first transfer to the plinth the patient's breathing became shallow and she appeared very anxious. After some work in sitting working on internal displacement we decided to try a sit to stand. She managed it well and only required moderate assistance of 2. However, once she was standing her breathing once more became quicker and shallower and she begged us to let her sit down. I checked her pulse while she was standing and although it had slightly increased, it was still strong and WNL. Also, her standing position had not changed and she was not utilising us for support any more than she was previously. I tried to engage her in conversation, asking her about the visitors I had seen in her room in order to distract her. Unfortunately, she wasn't able to communicate this as a result of her aphasia and began to swear and cry. We asked her to stand for 10 more seconds which she consented to and then allowed her to sit down. Once sitting her crying increased as she swore and apologised alternately between sobs.
I asked her what it was that was causing her to be upset, suggesting a few causes I thought most likely in order to make the communication easier. I soon found out that she felt as though she 'couldn't do it' and 'wasn't good enough' to be standing. She was very unconfident about her abilities despite being much better than some of my other patients who were also standing. I explained this to her, and tried to convey how well she was doing, with little success. After a rest, we were able to convince her to stand once more, which culminated in a similar teary conclusion.
I talked to her when she was back in her room and it was obvious to me that she genuinely wanted to do well and was extremely frustrated at her inability to comply with our instructions. I wasn't sure what else to do but provide encouragement and assurance that she was improving and that standing would get easier with each session.
Several things I learned from this encounter: sometimes you can do more harm than good when your patient has expressive aphasia and you ask them questions (particularly if they are easily discouraged and you are doing an exercise), even when patients are being particularly trying they often still have good intentions, and just because a patient is crying doesn't necessarily signal the end of the session. If anyone has any strategies on communicating with patients with expressive aphasia please share them.
The first session did not get off to a good start. Even before the first transfer to the plinth the patient's breathing became shallow and she appeared very anxious. After some work in sitting working on internal displacement we decided to try a sit to stand. She managed it well and only required moderate assistance of 2. However, once she was standing her breathing once more became quicker and shallower and she begged us to let her sit down. I checked her pulse while she was standing and although it had slightly increased, it was still strong and WNL. Also, her standing position had not changed and she was not utilising us for support any more than she was previously. I tried to engage her in conversation, asking her about the visitors I had seen in her room in order to distract her. Unfortunately, she wasn't able to communicate this as a result of her aphasia and began to swear and cry. We asked her to stand for 10 more seconds which she consented to and then allowed her to sit down. Once sitting her crying increased as she swore and apologised alternately between sobs.
I asked her what it was that was causing her to be upset, suggesting a few causes I thought most likely in order to make the communication easier. I soon found out that she felt as though she 'couldn't do it' and 'wasn't good enough' to be standing. She was very unconfident about her abilities despite being much better than some of my other patients who were also standing. I explained this to her, and tried to convey how well she was doing, with little success. After a rest, we were able to convince her to stand once more, which culminated in a similar teary conclusion.
I talked to her when she was back in her room and it was obvious to me that she genuinely wanted to do well and was extremely frustrated at her inability to comply with our instructions. I wasn't sure what else to do but provide encouragement and assurance that she was improving and that standing would get easier with each session.
Several things I learned from this encounter: sometimes you can do more harm than good when your patient has expressive aphasia and you ask them questions (particularly if they are easily discouraged and you are doing an exercise), even when patients are being particularly trying they often still have good intentions, and just because a patient is crying doesn't necessarily signal the end of the session. If anyone has any strategies on communicating with patients with expressive aphasia please share them.
Apparently you can give a pt too much information!
I was treating a man who had recently been diagnosed with bowel cancer and consequently undergone surgery resulting in a permanent stoma bag. The pt had complications which sent him to ICU for 2 weeks and this prolonged bed rest had lead to marked deconditioning and balance problems, which is what I was seeing him for.
He was very inquisitive and asked a lot of questions, so I made sure I gave him all the information I could and when I explained the functional reasons behind tests/exercises we were doing, he was always compliant and sometimes even enthusiastic. During the early stages he was so deconditioned that we would only be able to do a few items on the Berg and this would take half an hour or more, as his exercise tolerance was very limited. He required prolonged rests and water breaks before continuing. It was during this time that I thought I was doing a good job building rapport with the patient and answering his many questions. He was often upset with his condition and was very frustrated with his current abilities – he’d entered hospital, seemingly well and now couldn’t self transfer. He needed a lot of reassurance and emotional support.
As the patient’s exercise tolerance rapidly increased, his rest periods were not required as frequently, but as I had set a precedent of talking through his condition and our treatment, there seemed to be more chatting than exercising. I tried multi-tasking but he concentrated so hard on his exercises that he wasn’t able to do them as we talked. The patient really appreciated the explanations and the support, but it really wasn’t conducive to achieving the physical outcomes of our sessions. I was a bit disheartened when my supervisor suggested I wasn’t being very effective, as this was in stark contrast to the feedback the patient and his family had given me. Though I appreciate that my supervisor has a lot more clinical expertise than the family and realise now that he was, of course, right.
I decided to give the patient a ‘home exercise program’ (though he was still an inpatient!) and only after quite a lengthy discussion about the merits of doing unsupervised exercise.. As he got stronger I was able to give him more tasks to do unsupervised and eventually he seemed to be doing more exercises outside our sessions than in them! I thought this worked really well and the patient progressed quickly, without compromising the support I was giving him.
My reflection is about finding a balance between achieving our goals and those of the patient, and also about realising our limitations not only as students, but when we are physios. I think in this situation, whilst I got along well with the patient, I should’ve utilised other allied health professionals to assist in achieving our common goals, rather than trying to do it all myself!
He was very inquisitive and asked a lot of questions, so I made sure I gave him all the information I could and when I explained the functional reasons behind tests/exercises we were doing, he was always compliant and sometimes even enthusiastic. During the early stages he was so deconditioned that we would only be able to do a few items on the Berg and this would take half an hour or more, as his exercise tolerance was very limited. He required prolonged rests and water breaks before continuing. It was during this time that I thought I was doing a good job building rapport with the patient and answering his many questions. He was often upset with his condition and was very frustrated with his current abilities – he’d entered hospital, seemingly well and now couldn’t self transfer. He needed a lot of reassurance and emotional support.
As the patient’s exercise tolerance rapidly increased, his rest periods were not required as frequently, but as I had set a precedent of talking through his condition and our treatment, there seemed to be more chatting than exercising. I tried multi-tasking but he concentrated so hard on his exercises that he wasn’t able to do them as we talked. The patient really appreciated the explanations and the support, but it really wasn’t conducive to achieving the physical outcomes of our sessions. I was a bit disheartened when my supervisor suggested I wasn’t being very effective, as this was in stark contrast to the feedback the patient and his family had given me. Though I appreciate that my supervisor has a lot more clinical expertise than the family and realise now that he was, of course, right.
I decided to give the patient a ‘home exercise program’ (though he was still an inpatient!) and only after quite a lengthy discussion about the merits of doing unsupervised exercise.. As he got stronger I was able to give him more tasks to do unsupervised and eventually he seemed to be doing more exercises outside our sessions than in them! I thought this worked really well and the patient progressed quickly, without compromising the support I was giving him.
My reflection is about finding a balance between achieving our goals and those of the patient, and also about realising our limitations not only as students, but when we are physios. I think in this situation, whilst I got along well with the patient, I should’ve utilised other allied health professionals to assist in achieving our common goals, rather than trying to do it all myself!
Post natal education
My previous placement was at a women’s health facility. Patients who were referred by the nurses or who needed to be reviewed from the previous day were the highest priority patients. Once these patients had been seen the remaining patients had to be given post natal education.
Women who have had uncomplicated vaginal births are only in hospital for 2-3 days and those with caesarean sections 3-5 days, therefore there is a large turnover on the wards. There isn’t time to give everyone a 30 minute education session, so those patients who cannot be seen are given information booklets and are told to contact physiotherapy if they want to.
I decided to give a 16 year old girl post natal education because I believed she would really benefit from pelvic floor exercises and back care. I began by teaching her pelvic floor muscle exercises and good bowel and bladder habits. During the explanation she would not maintain eye contact and looked very disinterested. In addition she refused to practice pelvic floor muscle exercises and transverse abdominus exercises as she was in too much pain. I decided to stop the education session and didn’t continue with back education. I gave her the information and told her to contact the physiotherapy department with any problems.
I was quite frustrated following this education session because the information I was providing was extremely important for this young girl. I took her response quite personally and I felt that the treatment had been ineffective and a waste of time. I’m unsure why she wasn’t responsive. It may have been her pain levels, information overload or I may have caught her at a bad time. Seeing as though I am only 21 years of age she may have been more responsive to an older physiotherapist. After leaving the room my supervisor acknowledged that I had recognised and identified non verbal cues from the patient and had responded in an appropriate manner.
This treatment was a learning experience. I realised that many factors may have contributed to her being disinterested in the information that I was providing and I shouldn’t take her response personally. For this young lady the birth was probably very overwhelming. Although this patient would benefit hugely from this information I understood that if she wasn’t responsive I should provide education to more receptive patients on the ward who would appreciate the information.
During future education sessions I was quicker at responding to non verbal cues. If uninterested, I gave a more brief explanation and gave them the booklets to have a read. I expanded on education sessions when the patient was receptive and interested. I didn’t take their response personally and understood that the new mothers were overloaded with information and were experiencing a very new and challenging time of their life.
Women who have had uncomplicated vaginal births are only in hospital for 2-3 days and those with caesarean sections 3-5 days, therefore there is a large turnover on the wards. There isn’t time to give everyone a 30 minute education session, so those patients who cannot be seen are given information booklets and are told to contact physiotherapy if they want to.
I decided to give a 16 year old girl post natal education because I believed she would really benefit from pelvic floor exercises and back care. I began by teaching her pelvic floor muscle exercises and good bowel and bladder habits. During the explanation she would not maintain eye contact and looked very disinterested. In addition she refused to practice pelvic floor muscle exercises and transverse abdominus exercises as she was in too much pain. I decided to stop the education session and didn’t continue with back education. I gave her the information and told her to contact the physiotherapy department with any problems.
I was quite frustrated following this education session because the information I was providing was extremely important for this young girl. I took her response quite personally and I felt that the treatment had been ineffective and a waste of time. I’m unsure why she wasn’t responsive. It may have been her pain levels, information overload or I may have caught her at a bad time. Seeing as though I am only 21 years of age she may have been more responsive to an older physiotherapist. After leaving the room my supervisor acknowledged that I had recognised and identified non verbal cues from the patient and had responded in an appropriate manner.
This treatment was a learning experience. I realised that many factors may have contributed to her being disinterested in the information that I was providing and I shouldn’t take her response personally. For this young lady the birth was probably very overwhelming. Although this patient would benefit hugely from this information I understood that if she wasn’t responsive I should provide education to more receptive patients on the ward who would appreciate the information.
During future education sessions I was quicker at responding to non verbal cues. If uninterested, I gave a more brief explanation and gave them the booklets to have a read. I expanded on education sessions when the patient was receptive and interested. I didn’t take their response personally and understood that the new mothers were overloaded with information and were experiencing a very new and challenging time of their life.
Trying not to shout at the hearing impaired
On my last placement, we had a range of conditions presenting in the gerontology field. And a range of cultures too. One patient I treated, with my supervisor present, was an elderly German female with balance problems. When trying to get her subjective history, I found she was having difficulty hearing me. She had a hearing aid and impairment in the ear furtherest from me and reported no difficulty on the near side. I also inched my chair closer until I was very close. None the less, I began to speak louder as she asked me to repeat the questions. She still could not understand me. I tried to be very specific and brief with my questions, using single phrases and step-by-step questioning. Still she struggled to understand me. I was using very simple English, but still no progress. We were both getting frustrated and I was running out of ideas.
My supervisor repeated one of my questions to the patient from the other side of the room. To my surprise, the patient heard her clearly and responded appropriately. The supervisor was sitting on the side that the patient reported a hearing impairment. I was really stumped. It wasn't the language, the distance or the phrasing that was a barrier. So it must be volume or the patient's quality of hearing with the near-side ear. I don't think volume was the problem - I was being as loud as I could with out yelling. So I now conclude that it was related to my position in regards to her hearing.
Just because a patient is diagnosed with a hearing impairment on one side does not mean the other ear is normal. Just because we are given a set of facts, does not discount the room for change, error and thinking outside the box. I never thought of trying to change my position at the time. I wish I had to see if it was the key factor. But as physiotherapists we always need to think outside the square and see the link. Might mean we stop yelling at our patients when it is a language barrier that is the problem, or speaking as though to a two-year old when they can't hear!
My supervisor repeated one of my questions to the patient from the other side of the room. To my surprise, the patient heard her clearly and responded appropriately. The supervisor was sitting on the side that the patient reported a hearing impairment. I was really stumped. It wasn't the language, the distance or the phrasing that was a barrier. So it must be volume or the patient's quality of hearing with the near-side ear. I don't think volume was the problem - I was being as loud as I could with out yelling. So I now conclude that it was related to my position in regards to her hearing.
Just because a patient is diagnosed with a hearing impairment on one side does not mean the other ear is normal. Just because we are given a set of facts, does not discount the room for change, error and thinking outside the box. I never thought of trying to change my position at the time. I wish I had to see if it was the key factor. But as physiotherapists we always need to think outside the square and see the link. Might mean we stop yelling at our patients when it is a language barrier that is the problem, or speaking as though to a two-year old when they can't hear!
Sunday, May 25, 2008
adapting quickly to the situation
On my second placement, I had a patient who sustained a head injury who was then in the high dependency unit after cranial surgery. I was going to start assessing her but the nurse came by and said that she needs to be taken downstairs in 10 minutes to undergo x-ray for her lungs secondary to the presence of sputum post surgery. There were many patients to be seen that day so I had to maximise my time with her by prioritising the most important things. However, still intent on being thorough, I started conducting a full assessment of the ROM and strength of the UL and LL.
After the session my supervisor talked to me and said that it is fine to do a thorough assessment of the ROM and strength but I should have prioritised assessing the most important things that would verify whether or not she can stand up and do transfers from bed to chair and back, since I did not have enough time. That is, just the strength of the muscles she would need to stand up. I was planning to assess these along with many other things but I realised that I failed to see these as the priority in that particular situation. Also I somehow panicked a bit when I was told by the nurse that the patient will be taken somewhere in several minutes.
That experience made me realise how things can change quite quickly in such settings and that more often than not, they require a great degree of adaptability on my part and everyone else concerned. I have learned that circumstances like that are inevitable, especially in hospitals. It is important to be always ready for changes in circumstances and be calm enough to be able to make good decisions that optimise the time of everyone concerned. Another thing that I have learned is to constantly liaise with other health professionals concerned (ie, doctors, nurses, OTs, SPs, social workers) to use my time more efficiently. When I face the same situation next time, I will ascertain and analyse the immediate and most relevant needs of the patient very carefully and base my assessment and treatment on that. As with making myself calm in any situation, that comes with practice.
Amputation Expectation
A gentleman in his mid 60’s was admitted to hospital to have a number of toes amputated due to Peripheral Arterial Disease that had progressed to gangrene. After returning from surgery the patient was informed that due to the gangrene his forefoot had been amputated. The doctors informed the patient there was a possibility of more surgery depending on further investigations. Consequently the patient was taken back to surgery the following day and a below knee amputation was performed.
I saw the Mr A the afternoon after his first surgery to explain my role, get a history and develop a plan with the patient towards his discharge. The patient informed me that he is the primary carer for his wife who requires assistance with most tasks including feeding, bathing and transfers. Mr A was quite concerned about what level he would be able to return to and how long he would take to recover, particularly as his wife was currently in temporary care. Mr A felt that the doctors had not made it clear that they would do more than amputate his toes, however after our discussion he felt that he would be able to return to a sufficient functional level with the forefoot amputation.
When I went to see Mr A after his below knee amputation surgery it was like I was confronted with a different person. He was very emotional about his situation, ranging from anger at his situation and the doctors for taking off his leg, to despair that he would no longer be able to function to look after himself, let alone continue to be the carer of his wife. I had intended to see the patient to attempt some basic exercises and education but instead I spent time talking with the patient and trying to help him understand his situation.
I found this situation quite hard to manage due to the fact that I had told the patient what he could expect with a forefoot amputation and built up expectation that he would be able to function at a certain level, only to have these expectations then shattered by the further surgery. I felt like I had contributed to this patient’s problems by building up plans that were largely not achievable.
Looking back at the situation I could have gathered more information about the likelihood of further surgery from the senior nurses and medical team, which potentially would have changed my approach for future planning and education with the patient. However until the investigations are done and a decision to have more surgery is made, the patient needs to be treated for their current condition.
Friday, May 16, 2008
Changing Tact...
I undertook a Peadiatric Placement first off this year, and came across a few challenging situations. The extent to which we study Peadiatric topics is no where near as much as our core units, and although we cover a lot of important topics, there is no real mention of behavioural problems or how to deal with kids in pain. This sort of thing really only comes from experience. I guess it would make an interesting unit “how to deal with a 5 y/o who has behavioural issues and is in pain” and although a long-winded title, I’m sure it would be an interesting unit!
I had been on prac for a few days and was in the orthopaedic area. Up until this day, all the kids I had come into contact with were fairly well behaved and compliant to physio treatment. I also realised later that all the previous patients I had seen, had all been over the age of about 10.
The first day I was allocated to treat this particular patient, I actually heard her before I saw her. I was entering the ward, and heard this incredible high-pitched screaming coming from a room. Little did I know at the time this was to be my patient…
I read her notes; she was a 5 y/o aboriginal girl from up north who had a diagnosis of septic arthritis of her L ankle. She had undergone a ‘wash out’ in surgery the previous night and was due for physio treatment today to encourage movement of her ankle.
I entered her room with my supervisor and was surprised to see this little girl now squealing with laughter as she was playing a game with her mum. After introductions and explanations of why we were there, we started to head off to the physio treatment area. To give an overall idea of how this girl behaved, there was approx 10 distinct changes between screaming, sulking and laughing in the time it took to get to the physio area (about 1 ½ mins)
She was eager to show me how she could walk using the K walker, which she did keeping her L hip and Knee fully flexed so her foot was very far off the ground. When I attempted to show her that she could relax her hip and knee and still just keep her foot off, she refused and screamed that it hurt. So we changed activities; I began by distracting her and hitting a balloon around, so get the focus off her foot. Once she had settled down and was happy again, we tried to get her to move her foot by making patterns in talcum powder that was on the floor. She refused at first, then began by moving her hip and knee to move her foot instead of her ankle, when we tried to correct the technique she screamed and said it hurt.
I then used the balloon again and she started laughing and playing, and then attempted the ankle movements with the same result. I wasn’t sure how much I should continue persisting with the ankle ROM exercises or just do general activities. And I wasn’t sure how much her ankle truly hurt or if she was using it to get her own way. After about 20 mins of treatment, this little girl had not done anything I had asked and had continued to be demanding and scream if she didn’t get what she wanted.
I came out of this treatment session feeling like I had not achieved anything, as I hadn’t done what was asked to do, which was get her ankle moving. I told this to my supervisor, who said I had attempted to do what was asked, but she had behavioural issues, which made it difficult. She said I had done really well in building rapport with this little girl, but that I needed to know when to change tact in terms of exercises.
As the placement went on, my aim was to have multiple exercise ideas lined up, so that if I was faced with a similar situation again, I could quickly change tact and attempt another. I still think it is probably something that you just get better at with experience!
A major learning experience I took away from doing this placement is that you have to be extremely creative with kids. There is no way you can use adult tactics and ask them to ‘move their ankle,’ because they wont! If anyone has any thoughts or ideas on how to know when to change tact or keep persisting with exercises, please feel free to respond!
I had been on prac for a few days and was in the orthopaedic area. Up until this day, all the kids I had come into contact with were fairly well behaved and compliant to physio treatment. I also realised later that all the previous patients I had seen, had all been over the age of about 10.
The first day I was allocated to treat this particular patient, I actually heard her before I saw her. I was entering the ward, and heard this incredible high-pitched screaming coming from a room. Little did I know at the time this was to be my patient…
I read her notes; she was a 5 y/o aboriginal girl from up north who had a diagnosis of septic arthritis of her L ankle. She had undergone a ‘wash out’ in surgery the previous night and was due for physio treatment today to encourage movement of her ankle.
I entered her room with my supervisor and was surprised to see this little girl now squealing with laughter as she was playing a game with her mum. After introductions and explanations of why we were there, we started to head off to the physio treatment area. To give an overall idea of how this girl behaved, there was approx 10 distinct changes between screaming, sulking and laughing in the time it took to get to the physio area (about 1 ½ mins)
She was eager to show me how she could walk using the K walker, which she did keeping her L hip and Knee fully flexed so her foot was very far off the ground. When I attempted to show her that she could relax her hip and knee and still just keep her foot off, she refused and screamed that it hurt. So we changed activities; I began by distracting her and hitting a balloon around, so get the focus off her foot. Once she had settled down and was happy again, we tried to get her to move her foot by making patterns in talcum powder that was on the floor. She refused at first, then began by moving her hip and knee to move her foot instead of her ankle, when we tried to correct the technique she screamed and said it hurt.
I then used the balloon again and she started laughing and playing, and then attempted the ankle movements with the same result. I wasn’t sure how much I should continue persisting with the ankle ROM exercises or just do general activities. And I wasn’t sure how much her ankle truly hurt or if she was using it to get her own way. After about 20 mins of treatment, this little girl had not done anything I had asked and had continued to be demanding and scream if she didn’t get what she wanted.
I came out of this treatment session feeling like I had not achieved anything, as I hadn’t done what was asked to do, which was get her ankle moving. I told this to my supervisor, who said I had attempted to do what was asked, but she had behavioural issues, which made it difficult. She said I had done really well in building rapport with this little girl, but that I needed to know when to change tact in terms of exercises.
As the placement went on, my aim was to have multiple exercise ideas lined up, so that if I was faced with a similar situation again, I could quickly change tact and attempt another. I still think it is probably something that you just get better at with experience!
A major learning experience I took away from doing this placement is that you have to be extremely creative with kids. There is no way you can use adult tactics and ask them to ‘move their ankle,’ because they wont! If anyone has any thoughts or ideas on how to know when to change tact or keep persisting with exercises, please feel free to respond!
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