Reflective Diary Entry Paper

Factual Strand

While at my Level II Fieldwork at a transitional rehab facility I treated a woman in her

80’s admitted for rehab post pneumonia, who also had moderate to severe vision, hearing, and

memory loss. My supervising OTR/L, who practiced primarily from a biomechanical model, told

me that our main priority was to improve her strength, endurance, and respiratory function. The

client was often hesitant to participate in therapy, so before her session I asked my supervisor for

advice. She told me that sometimes the patients are confused, and it is a matter of “tricking”

them into participating for their own benefit. She said that the patient was unmotivated and

pessimistic, but that it was our job to get her better. I was told to put the client on the arm bike

for the first 20 minutes and to watch from a distance because if she had no one to talk to, she was

more likely to continue her exercise which was what she needed.

I followed the direction from my supervisor for the first few days, with a strictly

biomechanical approach, but after noticing that the client continually withdrew socially and

continued to have episodes of emotional dysregulation, I changed my approach. I found that

taking the client for walks gave me the opportunity to discuss psychosocial components of her

health without interruption to her cardiovascular exercise. With time, the client felt more

comfortable with me and I found ways to address her anxiety, depression, spirituality, and social

isolation while satisfying my supervisor’s expectations. One intervention that illustrates this,

involved searching through a hymn book to identify her favorite songs to sing in her head as a

strategy for coping with anxiety. We did so in the individual therapy room which was more

private and quite than the gym, applied compensatory visual scanning strategies, and sang her

selected hymns together while progressing her unsupported standing tolerance.

 On my last day, when explaining to the client that I would be returning to school, she

gripped my hand and asked me for a hug. When giving her the hug she held onto me and told me

that I was her angel, and that she would miss me. This experience was significant to me as it

gave me clinical experience that progressed my understanding of the importance of mindfully

implementing theoretical models, advocating for client centered approaches, addressing

socioemotional health during functional intervention, and the value of establishing a strong

interpersonal therapeutic relationship.

Retrospective Strand

At the beginning of this experience, when being instructed to “trick” the client into

participation I felt confused and frustrated but had enough self-doubt in my clinical knowledge

and experience that I kept those feelings to myself and followed instruction. I was aware from

the beginning of this fieldwork that my theoretical orientation was different from my supervisors,

but what I didn’t recognize until reflecting on this experience, was how limiting my self-doubt

was. I doubted my knowledge and my instincts, so much so that I didn’t discuss the internal

conflict I was experiencing about this client’s care with my supervisor. While we had different

perspectives, I realize now that I disadvantaged both myself and the clients I served by not

finding a way to discuss my concerns with my supervisor. In an effort to avoid confrontation or

offense, I missed out on an opportunity to collaboratively address the concerns I had in providing

client-centered, holistic, and occupation-based approaches in this setting. Instead, I dealt with my

concerns internally and independently, which caused me to feel a sense of burden and frustration

which could have been lessened or avoided. If I had been more willing to have constructive

conversations with my supervisor, it could have contributed to a more effective and collaborative

learning environment.
 This client, who expressed feelings of extreme isolation from her deficits in vision and

hearing, needed a sense of connection as much as she needed to exercise her lungs. Once I was

able to establish that connection with her, she was no longer hesitant to participate in therapy, but

was eager to engage in each of our sessions. This woman was one of the clients that helped me

recognize some of my own strengths as a future therapist. Toward the end of my placement, I felt

protective of her and leaving her made me both sad and a little worried. I now feel regret that I

didn’t discuss this experience more directly with members the multidisciplinary team as it not

only limited my own growth, but possibly the standard of care for individuals like this client at

that facility. I was more worried about passing this fieldwork and establishing positive, yet

superficial, work relationships that I missed out on an opportunity to effectively provide a

different perspective. While I recognize that my opinions as a student intern wouldn’t necessarily

change the facilities priorities, I could have at least provided another perspective to possibly

facilitate their reflective practice.

Substratum Strand

I strongly value the recognition of psychosocial components of well-being. Having had

my own experiences of mental health barriers impacting my health and engagement, as well as

observing this in close friends and family members, has instilled this value within myself. This

has an inherent influence on how I see individuals, develop patient profiles, and intervention

plans. This is seen through my automatic response to hearing clients labeled as “unmotivated” in

my clinical experiences. Working in medical settings has highlighted a lack of understanding in

how psychological health can impact a person’s ability to engage in a variety of occupations and

is often seen as a character flaw. I have seen this stigma have a negative affect on individual’s

sense of self as well as their active engagement in daily activities.

 I also see incredible value in addressing clients as spiritual beings. I say this because of

my ontological, causal and agentic philosophical assumptions. I do not believe that people make

difficult or lasting changes in their behavior because of temporary rewards or punishment, but

that the most powerful influences are their spiritual beliefs of purpose and meaning. Reflection

on this subject has helped me understand that my approach to psychological well-being is not

about finding a hedonistic type of happiness, but instead a sense of meaning and purpose. This

looks different for everyone and through the development of a strong interpersonal therapeutic

relationship with this client, I learned that her religion underpinned much of her spiritual beliefs.

For that reason, we utilized hymns and scriptures as resources to cope with her anxiety and

depression, as well as bringing meaning to her daily life to counteract a sense of hopelessness

that was limiting her participation.

Connective Strand

The experience of working with this client, as well as the act of completing this

reflection, has highlighted multiple implications to my future practice. First and foremost is the

importance of utilizing a client centered approach that recognizes the reciprocal influences of the

person, environment, and occupations as a unique and evolving whole. Secondly, this increased

by recognition of how imperative it is to utilize a reflective and mindful practice, to avoid getting

stuck in habitual practice as an occupational therapist. While continuing education for licensing

encourages this, I am realizing the importance of personal reflection to ensure I incorporate

evidence and theory into my interventions to promote best practice.

I also recognize the importance of advocacy in practice. As a student completing Level II

fieldworks, I need to find a way to advocate for best practice and my client’s individual needs.

This will require me to feel more confident in my strengths, knowledge, and resources, in
addition to improving my skills as an active participant in an interprofessional team. I plan to be

mindful of this as I prepare for my last fieldwork and hope to establish open and regular

communication with my supervisor in an effort to support the progression of my clinical skills,

and ability to provide my clients with ethical and effective intervention. As part of my plan, I

also anticipate e-mailing my supervisor directly, before staring my fieldwork, to ask for her

preferences in communication. I plan to turn to my interprofessional team, as well as available

research if I find myself unsure of how to provide best practice, or in a similar situation when my

values or approaches differ from those established at the facility. By developing positive and

authentic professional relationships and clearly communicating my intent to provide optimal

intervention by progressing my clinical skills, I hope to create a supportive dialogue and

environment.