CLINICAL EDUCATION: AN ANALYSIS OFCLINICAL REASONING AMONGST

PHYSIOTHERAPY STUDENTS IN FIJI

by

Venasio Ramabuke

Supervised Research Project submitted in partial fulfillment of the

requirements for the degree of

Master of Education

Copyright © 2018 by Venasio Ramabuke

School of Education

Faculty of Arts, Law, and Education

The University of the South Pacific

April, 2018

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ACKNOWLEDGEMENTS

I would like to thank my research supervisor, Dr. Jeremy Dorovolomo, the

University of South Pacific Postgraduate Research committee, and the CMNHS

College Health Research Committee – for their assistance, guidance, and

encouragement throughout the development of my research.

I would like extend my sincere gratitude to Mrs. Maria Waloki – Head of

School of Health Sciences at the Fiji National University, Physiotherapy Associate

Professor – Dr. Ayodele Akinremi, and the Academic staff members of the

physiotherapy program for their continuous support and assistance.

Lastly, I would like to take this opportunity to express my deepest gratitude

to my wife, family, and friends for their ongoing support and encouragement

without which I would not have been able to complete this study.

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ABSTRACT

Clinical Education: An analysis of Clinical Reasoning Amongst Physiotherapy

Students in Fiji.

Clinical reasoning is a key competency in the physiotherapy clinical education

academic program. It is the thought process of clinical practice which is critical in

decision making of clinicians. Literature review on assessment of clinical reasoning

identified the Script Concordance Test as an assessment tool. 41 undergraduate

physiotherapy students from the Fiji National University were assessed on an aspect

of clinical reasoning, quantifying their ability to make decisions on ill-defined cues

via clinical vignettes in the Script Concordance Test. The Script Concordance test

with the ‘good’ level of clinical reasoning defined as scores within 2 standard

deviation of the expert clinicians mean score (57.7%) was the assessment tool used

to analyze diagnostic clinical reasoning in undergraduate physiotherapy students.

Year 3 students demonstrated a mean score of 59.32% ± 8.03 while the fourth years

scored a slightly higher mean score of 64.97% ± 10.17 in concordance to the

reference norms set by the expert clinicians. There were no significant differences

between the year 3 to year 4 (p value = 0.29) and the year 3 to the expert (p value =

0.40) scores. There were also no significant difference in the year 4 to the expert (p

value = 0.55) scores. Increasing exposure to clinical experience may have had some

effect on increasing levels of clinical reasoning but was not significant. Other factors

such as exposure to an environment that allows for harnessing of thinking skills may

be more important in leveraging clinical making abilities. Interventions that help

students make good decisions is crucial in training them to be good clinicians. The

SCT is a valid assessment tool for psychometric analysis of clinical reasoning

amongst physiotherapy students.

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LIST OF ABBREVIATIONS/SYMBOLS

BPT: Bachelor of Physiotherapy

IBM: International business machines

M: mean

MCQ: Multiple Choice Questionnaires

OSCE: Objective Structured Clinical Examination

p value: level of significance

r value: Pearson's correlation coefficient

SCT: Script Concordance Test

SD: standard deviation

SSPS: Statistical Package for the Social Sciences

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TABLE OF CONTENTS

Abstract………………………………………………………………………...….....ii

List of Abbreviations/Symbols……………………………………………………...iii

List of Tables………………………………………………………………..……....vi

List of Figures…………………………………………………………….……..….vii

Chapter One: Introduction to the Study………………………………….…………..1

1.0: Clinical education……………………………………………………….1

1.1: The Study……………………………………………………………..…3

1.2: Purpose of clinical education……………………………………………4

1.3: Research Aims and Objectives………………………….…………...….5

1.4: Research Questions……………………………………………………...5

1.5: Significance of the Study…………………………………….………….6

1.6: Assumptions………………………………………………………….….6

1.7: Preliminary definitions………………………………………………….6

Chapter Two: Background………………………………………………………...…8

Chapter Three: Literature Review………………………………………….………13

Chapter Four: Methodology……………………………...………….……….……..24

Quantitative approach………………………………………………………24

Action research……………………………………………………..………24

Sample…………………………………………………………………..…..25

Script Concordance Test Construction…………………...…….…………..26

Implementation Procedure………………………………………....……….28

SCT Analysis………………………………………..……….……………..29

Chapter Five: Result………………………………………………….…………….31

Analysis of expert Scores…………………………………………….....….32

Analysis of Student Scores…………………………………….………..….33

Chapter Six: Discussion………………………………………………………….....40

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Limitations……………………………………………………………….…44

Implications for physiotherapy education......…………………..….………45

Chapter Seven: Conclusion and Recommendation………........................................46

References……………………………………………………………………..……48

Appendix 1: Script Concordance Test…………………..……………..…………...53

Appendix 2: Research approval letter………….…………………………………...62

Appendix 3: University of the South Pacific Ethic approval……………………….64

Appendix 4: Participant Informed Consent form…...…………….……..………….65

Appendix 5: BPT Course prescription……………………….……………………..66

Appendix 6: BPT Clinical Assessment form………….…………………………....67

Appendix 7: Expert Clinicians SCT Raw Data……………………………..…..…..70

Appendix 8: BPT Year 4 SCT Raw Data…………………………………….….…74

Appendix 9: BPT Year 3 SCT Raw Data…………………………………….…….78

vi

LIST OF TABLES

Table Page

1. Overview of tools used to assess clinical reasoning including pros and cons of

each............................................................................................................................17

2. A Clinical vignette with the three items. ……………………………………….27

3. SCT Reference key from expert scores…..……………………………….…......32

4. Proportion of students with levels of CR class referenced…………………...….33

5. Proportion of students with levels of CR norm referenced……………………....34

6. Student SCT scores by specialty areas………………………………………..….34

7. Descriptive data for the SCT results from IBBM SPSS 24……………………...35

8. Pearson’s correlations and significant levels for relationships of the students and

expert SCT scores…………………………………………………….…………….37

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LIST OF FIGURES

Figure Page

1. Relationship between key steps in the clinical reasoning process and the format

of SCT items ……………………...………………….…………………………….20

2. Summary of the relationship between knowledge and reasoning paradigms with

clinical reasoning strategies……………………………………………….………..22

3. Result (mean ± SD) of student (BPT03 n=30, BPT04 n=11) SCT scores by the 5

specialist areas represented within the clinical vignettes…………………………...35

4. Script concordance test results……………………………………………..…….36

5. Normal distribution curve of BPT03 SCT scores………………………..………38

6. Normal distribution curve of BPT04 SCT Scores……………………………….38

7. Normal distribution curve of expert SCT scores…………………………….…..39

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Chapter One – Introduction to the Study

Introduction

This first chapter introduces clinical reasoning as a central process in the work of

clinicians such as physiotherapists. It contains the aims and objectives, rationale, the

research questions, as well as the assumptions of the study. The subtopics contained

in this chapter aims’ to enlighten the links and highlight the key issues which the

study aims to resolve.

1.0 Clinical Education

Clinical Education (CE) is a critical component of any medical, nursing, and

health science academic program. It encapsulates the authentic practice of the

profession and puts into practice, under supervision, the knowledge and practical

skills students have acquired from a theoretical classroom setting onto a real life

practice scenario. Health professionals across the disciplines of medical, nursing and

health sciences require competencies in clinical reasoning and decision-making to

complement proper practicing skills in order be effective in practice. For students

who are being developed into health professionals, virtuous decision making as well

as proper clinical reasoning are essential aspects of clinical practice within the

clinical education programs. Physiotherapy, being a discipline of health sciences, is

concerned with the provision of services that develop, maintain and restore a

person’s maximum movement and functional ability which may be threatened by

ageing, injury, diseases, disorders, conditions or environmental factors. Intervention

is through movement and exercise, manual therapy, education and advice (World

Confederation of Physical Therapists (WCPT), 2016). The College of Medicine,

Nursing, and Health Sciences (CMNHS) of the Fiji National University (FNU) is the

sole training institution of physiotherapists in Fiji and for majority of the South

Pacific islands.

Clinical reasoning (CR) is the substance of physiotherapy clinical practice

and clinical education. It can be defined as the process of thinking through the

various aspects of client care to arrive at a reasonable decision regarding the

prevention, diagnosis, or treatment of a clinical problem (Hawkins, Elder, & Paul,

2010). Clinical reasoning is the nucleus of physiotherapy clinical education as it

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determines the successful transfer of theoretical learning from a classroom setting

applied through clinical thought processes, determining the application of necessary

clinical knowledge and skills. A robust clinical education program is characterized

by an output of cohorts of graduate clinicians who are able to demonstrate high

levels of competency in various roles, skills, cognition, and metacognition which are

required for effectiveness at a practitioner’s level.

There are several models of clinical reasoning found in literature including

pattern recognition, Hypothetico-deductive or diagnostic reasoning, and narrative

reasoning (May, Greasley, Reeve, & Withers, 2008). In pattern recognition, the

clinician links presentations of the current client with previously seen clinical

problems and implements a previously-successful management strategy. In

Hypothetico-deductive reasoning, the clinician generates a hypothesis based on data

presented by the client, that is then tested, and further hypotheses are generated until

a management pathway is defined clearly. Narrative reasoning is a ‘process of

enquiry, examination and reflective management’ by which the clinician

understands the client’s problem, the patient’s perspective, and the context of that

problem (Jones & Rivett, 2004). It demands collective reasoning amongst the patient

and the clinician, effective communication by the clinician, and on-going reasoning

until a plan of management is agreed upon. Preliminary research and models of

clinical reasoning in physiotherapy provided justifications that were, to some extent,

similar to those of physicians and were mainly directed towards the diagnosis of a

case (Banning, 2007).

The Hypothetico-deductive model is the most persistent model in medicine

and was derived from a cognitive science perspective but had roots from the

empirico-analytical research paradigm (Gordon & Franklin, 2003). Manias, Aitken

and Dunning (2004), in the review of graduate nurses models of decision making to

manage patients’ medications, found that the Hypothetico-deductive reasoning was

the most common decision making model utilized. The empirico-analytical research

paradigm states that knowledge is measurable, thereby utilizing observations and

experiments to produce a result, in turn, can be generalized and also lead to

predictions for future events. Examples of theories from the cognitive science

(empirico-analytical) perspective include pattern recognition and the “illness scripts”

(script theory). The script theory founded illness script implies that clinicians

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through experience and reinforced through continuous exposure to similar cases,

develop organized sets of illness biomedical knowledge which they are able to draw

and utilize to help determine the diagnosis or management of similar cases.

This research attempts to seek solution to the research question that

academics of the physiotherapy program often inquire themselves with; what is the

level of clinical reasoning physiotherapy students acquire as a result of going

through the program? The central aim of this study is to analyze and document the

level of clinical reasoning amongst physiotherapy students in Fiji. Findings or

answering this question will help validate the effectiveness of the current clinical

education model used by the physiotherapy program at the Fiji National University

as well as to inform for better modifications to its current clinical education

program. An objective of the study will be to identify a valid and reliable method of

objectively assessing clinical reasoning. Once identified, the tool is implemented

and can be used in the future for analysis clinical reasoning as well as for future

benchmarking against national standards.

1.1 The Study

Clinical reasoning is an essential competency physiotherapy students should

be able to demonstrate while engaged in the clinical years of the bachelor of

physiotherapy program in order to assure clinical educators and employers they are

practice ready. A collective criticism raised by clinical educators as well as

supervising clinicians is that students lack worthy clinical reasoning skills whilst

practicing in the clinical years of the program as well as when they come out to

work following graduation (J. Kotobalavu, personal communication, January 28,

2016). Researching and documenting an assessment of this competency could

influence the review of the clinical education system currently used with in the

undergraduate program as well as validate assumptions.

An aspect of clinical reasoning is the ability to recognize similar patterns of

conditions and reactivating stored knowledge which leads to formation of correct

diagnosis and management of a presenting clinical scenario. The stored information

is known as the illness script (Charlin, Boshuizen, Custers, & Feltovich, 2007). The

diagnosis of a clinical condition is significant as it determines the management steps

that will be taken by the clinician. This research focuses on analyzing the diagnostic

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clinical reasoning amongst physiotherapy students using the Script Concordance

Test (SCT). The SCT is a clinical reasoning assessment tool which utilizes ill-

defined clinical vignettes. It was developed in 2000 by Charlin and collaborators

who aimed to assess clinical reasoning skills (Aldekhayel, ALselaim, Magzoub, AL-

Qattan, AL-Namlah, Tamim, AL-Khayal, Al-Habdan, & Zamakshary, 2012). The

written SCT analyses the effects of new clinical information has on students initial

hypotheses while encountering a case. This is very relevant to real life clinical

situations where clinicians have to make decisions based on ill-defined cues

gathered through client interaction. Approval for the research was granted by the Fiji

National University research committee and the Universities of the South Pacific

(Refer to appendices 2 & 3).

1.2 Purpose of Clinical Education

Physiotherapists practicing in clinical or public health settings are obliged to

be aware and carry out practice in adherence to client safety on a daily basis even

though they may not understand the scope of the issue (King & Anderson, 2010).

Client safety has been defined as “the reduction and mitigation of unsafe acts within

the health-care system, as well as through the use of best practices shown to lead to

optimal client outcomes” (Canadian Patient Institute, 2003). As a result

physiotherapists must be able to make highly effective and efficient clinical

decisions based on a well-informed clinical reasoning process in-order to maintain

high quality client care and achieve positive intervention outcomes (King &

Anderson, 2010).

Training institutions play a major role in shaping the way graduates clinically

practice. Health care students are trained in various competencies to prepare them in

the best way possible in order to fit into the requirements of the position they adopt

as clinicians. Assessing the ability to clinically reason through recognition of similar

condition pattern and retrieve stored illness information (illness scripts) based on

experience from previous encounter and duration of exposure to similar clinical

scenarios in students, provides a feedback on the effectiveness of the clinical

education and the general education system utilized by the program. It also provides

an indication of the strength and stability of the clinically acquired illness scripts

cognitive networks students have developed as a result of a structured clinical

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education curriculum they undergo. On the other hand, as practitioners, clinical

physiotherapists need to demonstrate high levels of clinical reasoning in order to be

accountable and effective in their daily practice.

As academics of the physiotherapy undergraduate program and as a

professional physiotherapist, it is imperative to assess the efficacy of the current

clinical education model used in the education of future professionals. Through an

analysis of the basic competency of clinical reasoning, an insight into the strengths

and weakness of the current clinical education curricula can be revealed. A robust

physiotherapy educational system or model will determine the caliber of

professionals that will be produced by the program. This is an institutional as well as

a regional concern as the Fiji National University is responsible for the training of

physiotherapists in Fiji and a majority of the South Pacific region.

1.3 Research Aim and Objectives

The main aim of the research is to analyze clinical reasoning amongst

physiotherapy students in Fiji. The research was conducted with the following

objectives;

1. To conduct a thorough literature review on clinical reasoning and to

identify a reliable objective tool of assessment that could be used to quantitatively

assess clinical reasoning in physiotherapy students.

2. To quantitatively assess clinical reasoning of undergraduate physiotherapy

students at the Fiji National University through implementation of the tool identified

from the literature search.

1.4 Research Questions

The study aims to answer the research question: what is the level of clinical

reasoning of undergraduate physiotherapy students at the Fiji National University

when compared to the clinicians who are currently practicing? Various claims have

been made on the level of clinical reasoning students graduate with before entering

the job market. However, estimations of clinical reasoning levels students and

graduates acquire have been subjective as there has been no objective assessment of

this competency. Reflection on findings to assess implications for physiotherapy

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curriculum and the conduct of clinical education within the current physiotherapy

program will be an implication of the study.

The lack of objective assessment of clinical reasoning poses a huge problem

as there are no evidences of the ability of the trainee physiotherapists to make

adequate decisions in practice. Knowledge and skills assessments have been carried

out but without the assessment of decision making ability of the students, the

employers and decision makers may not be fully informed of the capabilities of the

students and graduates in a very important competency.

1.5 Significance of the Study

The study is significant in that the objective assessment of clinical reasoning has

never been carried out before on physiotherapy students in Fiji. Clinical reasoning is

a central process in clinical practice and therefore requires a proper evaluation whilst

future professionals are being trained to fulfill the roles they are expected to carry

out as clinicians who are capable of making good decisions.

1.6 Assumptions

The research is working on the assumption that undergraduate physiotherapy

students have levels of clinical reasoning that are somewhat similar to expert

physiotherapists who are practicing. The levels of clinical reasoning students

develop as a result of the clinical education curriculum of the Bachelor of

physiotherapy program prepares students to begin practice at a somewhat safe level.

It is understood that as years of clinical practice go by, they will enhance this

baseline level and therefore improve to an advanced level over time. From the point

of view of clinicians, the research assumes that the level of clinical reasoning of

clinicians, of which the student scores will be referenced against, is at a level that is

significantly higher than the average student level. The result of the study will

ascertain if the assumptions were correct or not.

1.7 Preliminary Definitions

BPT – Bachelor of physiotherapy is the primary physiotherapy qualification in Fiji.

Clinician – A health or medical personnel who actively practices the profession in

the clinical set up.

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Clinical Education – Health care education conducted in health care facilities,

outpatient clinics, emergency centers, hospitals, or private offices, under the

supervision of a qualified practitioner or teaching staff.

Clinical expert – physiotherapist who has completed the internship and is fully

practicing in the profession.

Clinical reasoning – the thought process behind the practice. The cognition informs

the practice of clinicians which determines how they practice.

Client – refers to a person who presents to a physiotherapist for his/her professional

service.

Cronbach's alpha - is a measure of internal consistency, that is, how closely related a

set of items are as a group. It is considered to be a measure of scale reliability.

Hypothesis - is what the clinician or student is trying to authenticate or refute in the

study or examination (Polit & Beck, 2008). It is a projected connection between

variables or predicted outcomes.

Physiotherapy – A profession that deals with helping restoration of movement and

function when someone is affected by injury, illness or disability.

Physiotherapist – a professional who have studied and graduated with a basic

physiotherapy qualification.

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Chapter Two – Background

Introduction

This chapter reflects back at the historical background of the physiotherapy

profession from its establishment to how it came to be part of the work profession in

Fiji. It also looks at the physiotherapy academic program from inception to its

current status as an institution responsible for the training of future physiotherapy

clinicians for Fiji and the South Pacific island countries.

Physiotherapy profession

Physiotherapy is a health care profession that assesses, diagnose, treat, and

manage conditions which may affect movement or cause movement disability.

Intervention is through physical means such as exercise, manual techniques,

electrotherapy, and client education. Physiotherapists or physical therapists work in

a wide range of settings within the public and private sectors from acute care, to

rehabilitation, sports, and the community. They work as part of a group of medical,

nursing, rehab and healthcare workers functioning in a multidisciplinary role for the

universal care of the client. Physiotherapy operates on disciplines or specialties.

These broad specialist areas include musculoskeletal, cardiorespiratory, and

neurological physiotherapy. Sub disciplines include women’s health, sports

physiotherapy, geriatrics, pediatric and burns physiotherapy.

Physiotherapists in the United States evolved during the era of World War 1

around 1917 (Australian Physiotherapy Association (APA), 2017). The service was

developed as a response to the need for services that were necessary for soldiers

during the war. Initially they were known as ‘reconstruction aides’ and were

individuals who had graduated from other academic degree areas. The first known

therapists graduating from physiotherapy program were from Reed College and

Reed hospital. As the profession developed, they expanded their services to those

affected by the great poliomyelitis epidemic that ravaged around 1920. As was the

case in the United States, other parts of the world had early physiotherapists

developing from technicians.

In New Zealand, historical archives reveal records of initial registration for

practice in 1921 (Physiotherapy New Zealand (PNZ), 2017).Today the profession

9

has developed into specialty areas within its domain of service to include areas such

as acute care, cardiopulmonary, neurology, musculoskeletal, sports, women’s health,

gerontology, clinical electro and wound management, education, pediatric and

research. Currently there are more than 30 physiotherapists all over Fiji majorly

stationed in physiotherapy departments within the divisional and major hospitals.

Whilst a majority of them are employed by the government serving in the public

hospital clinics, there is a rapid growth in the private sector where a growing number

of physiotherapists operate in their own private clinics and attached to institutions

such as sports institutions and business houses.

Training for health professionals in Fiji began in the 1940’s. The

physiotherapy training program was introduced in 1961 by New Zealand

physiotherapists who were working in Fiji during that time. This initial training was

basically an apprenticeship influenced mainly by the clinician’s basic training and

experiences. This consisted of mainly hands on training with very little formal

theoretical sessions.

In 1984, the qualification of a certificate in physiotherapy program was

introduced at the former Fiji School of Medicine (now known as the College of

Medicine, Nursing, and Health Sciences). The program did not undergo intensive

scrutiny and review and had various gaps and lacked basic teaching and learning

principles which must underpin such educational programs. In 1997, the Diploma in

physiotherapy program was introduced at the school. In 1999, the first cohort of

Diploma in physiotherapy students graduated from the Fiji School of Medicine

having undergone three sets of two semesters per year of intensive training. The

Diploma in physiotherapy program was the result of the curriculum designed by a

lecturer of the Diploma in physiotherapy program, Mrs. Maria Buabeta Waloki, as

part of her Master of Health Science Education she was undertaking at that time

from the University of Sydney. The program was later upgraded into the current

Bachelor of Physiotherapy program in 2009 after passing through the Fiji National

University academic program screening and verification processes. The first cohort

of the four year-long Bachelor of physiotherapy program graduated in December

2012.

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Apart from the South Pacific education power houses of Australia and New

Zealand, the Fiji National University’s physiotherapy program is currently one of

the only two Physiotherapy academic programs existing within the South Pacific

islands. The other one is the Bachelor of physiotherapy program at the Divine Word

University in Papua New Guinea. Students from all over the South Pacific islands

undergo physiotherapy training at the Fiji National University in preparation for

service provision in their own countries upon completion of training. In Fiji, the

majority of the physiotherapy clinicians are employed at the public sector as civil

servants under the Ministry of Health. A small percentage are in the private sector

working as private clinicians while an even smaller number are employed full time

by national sporting bodies such as the Fiji Rugby Union (FRU) and Fiji Football

Association (FFA).

The Fiji Physiotherapy Association (FPA) is the peak body for the profession

in the country. Physiotherapy students are eligible for membership into this

professional body as student members. The FPA maintains the standards of conduct

and expertise of the physiotherapy profession in Fiji. It also promotes the welfare

and serves to preserve and maintain the integrity and status. All graduates are

expected to be registered and licensed for practice by the Fiji Allied Health

Practitioners Council through membership of the FPA. The FPA is a member of the

World Confederation of Physical Therapists (WCPT) which is the world body for

the profession.

The Bachelor of physiotherapy program at the Fiji National University is a 4

year degree program. There are 27 courses in the program spread out over 12

semesters. The first two years of the program is a foundational buildup of

biomedical sciences knowledge and basic physiotherapy skills competency which

will be later utilized in the clinical years of year 3 and 4. The current curriculum is

due for a major review which may bring about necessary changes to the curriculum

to reflect the current health issues such as the problem of non-communicable

diseases in the Pacific regions. Such reviews usually result in changes to focus

therefore implicating the structure, delivery, and outcomes of the program.

In the 3rd and 4th years of the program, students undertake seven blocks of

clinical attachments to the local hospitals such as the C.W.M Hospital, Lautoka

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Hospital, community-based rehabilitation centers and senior citizen homes. Each

block in the third year level has 6 weeks of clinical practice. For those 6 weeks, they

work 7 hours a day. In total, a block at the third year level offers 252 hours of

practice. In a year, the annual total hours of clinical practice totals up to 756 hours.

Within these clinical blocks, students undergo clinical exams towards the end of a

block and they are expected to pass all the blocks before they can proceed to the

next block. Towards the end of their fourth year of study, as part of their exit

assessment, they undergo a clinical examination which is conducted and assessed by

an external examiner. Their performance in the clinical exit exam is a major

deciding factor to passing the exit examination and graduating from the program.

Graduating candidates are expected to pass the clinical exam that will be conducted

by an external examiner; usually a senior academic staff from an external university

from the physiotherapy faculty.

The clinical attachments are used as a teaching and experience gaining

opportunity for students where they put into practice what they have learnt via

primarily theoretical sessions complemented by practice on non-real client situations

over the first 2 years of the program. Clinical examinations towards the end of a

block are carried out with the use of the program standard clinical examination form

(Appendix 6). Assessments are based on a clinical examination form which has

components of physiotherapy skills in client assessment both subjective and

objective, treatment, knowledge, communication, and professionalism. There is an

assessment item on clinical reasoning which is rather vaguely constructed within the

assessment form. However, the proper assessment and quantification of clinical

reasoning is not emphasized enough from the current clinical assessment. Clinical

reasoning is a central component to clinical practice and therefore needs to be

emphatically evaluated continuously and in detail as part of the clinical education

assessment for physiotherapy students.

In summary, the physiotherapy profession is based on the impression of

maximizing or enhancing physical bodily movements which may have been

influenced by diseases or disability. Physiotherapy originated in the United States

after the world war 1 before coming to the pacific through New Zealand and

Australia. The Fiji National University’s physiotherapy program aims to train future

12

clinicians to be good clinical decision makers in order to support them in their daily

practices.

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Chapter Three – Literature Review

Introduction

Included in this literature review is an examination of the Script Theory

which forms the conceptual framework for the use of SCT as an assessment tool for

assessing clinical reasoning in health professionals. A review of clinical reasoning

which is a pivotal component of clinical practice and the SCT as a valid tool for the

assessment of clinical judgement based on uncertainty will be presented.

3.0 Clinical decision making

All health care providers including doctors, nurses, and health science

professionals are faced with making compound decisions with a high degree of

uncertainty that are based on ill-defined or complex client presentations. Therefore it

has become a focus as well as a challenge for medical and healthcare academic

programs to provide adequate training and development of student’s cognitive and

metacognitive skills to cope with the demands of clinical decision making. While

recent studies on clinical reasoning specifically in physiotherapy students are

limited, there have been numerous medical and nursing studies over the decades on

clinical reasoning that can be applied to physiotherapy and present a better

conceptualization of clinical decision making. However, the challenge of

quantitative evaluation of this qualitative phenomenon in cognition has persisted to

be an ongoing obstacle for education providers and therefore implies the need for the

development of a valid and reliable assessment tool for clinical reasoning (Caire,

Sol, Moreau, Isidori, & Charlin, 2004; Charlin, Gagnon, Sibert, & Van der Vleutin,

2002). Clinical reasoning is a function of knowledge, attitudes, and reflective

professional practice. It is judged by the correctness of the interventions performed

in the wake of a decision making process (Higgs & Jones, 2000). This is a vital

progression in the assessment and management of clients in the nursing, health

sciences and medical fields. Physiotherapy students graduate and are expected to

function clinically with a certain level of clinical reasoning competency that is

somewhat safe for independent practice in the workplace. This literature review

focuses on studies on clinical reasoning in the physiotherapy and related health

sciences profession.

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Before an assessment tool for clinical reasoning can be developed, a clear

definition for what is being assessed must be established. According to Deschenes,

Charlin, Gagnon, & Goudreau, (2011), clinical reasoning is a cognitive and

compounded process with the demand for good decision base integrated into every

decision a clinician makes. With the rising demand brought about by increasing risk

for liability claims, clients are presented with increased opportunities to ask

questions and to know the reasons through every step of their therapy treatment and

management process (Tan, Ladyshewski, & Gardener, 2010). This places increased

demands on clinician’s metacognitive skills utilization to facilitate arriving into an

informed clinical judgment that is transparent, evidence based, sound and safe. Early

studies in physiotherapy clinical reasoning showed that most initial reasoning

models were similar to those of physicians which were centrally concerned with

diagnosis of the case (Payton, 1985). This was in support of the Hypothetico-

Deductive model of clinical reasoning.

In a clinical setting, clinicians as well as practical students are constantly

faced with cases or conditions that are poorly defined, goals that are multifaceted

and outcomes that are ill predicted therefore contributing to the multidimensional

context in which the complex process of clinical reasoning takes place. Checkland

(1981) had categorized the health care system as a ‘soft system’ in reference to such

systems that had ambiguous goals and outcomes. Uncertainty is a proper description

of the environment that surrounds clinical decision making. Defined professional

judgments and decision making within the ambiguity and uncertain scenario of

health care is definitely a complex situation that necessitates clinician’s reflection on

their practice as well as exceptional skills in clinical reasoning. Skills of expert

decision making and precarious self-appraisal are necessary to keep up with the

information processing limitations which results in constraints to clinician’s and

student ability to access the knowledge and solve the problem.

3.1 Cognitive process

Research exploring physiotherapists’ clinical reasoning processes show that

they use the cognitive processes of Hypothetico-deductive reasoning and pattern

recognition to make judgments regarding diagnosis (Edwards et al., 2004; Plummer

et al., 2006). Higgs and Jones (2000) also suggest that a process of generating and

15

testing hypotheses is used to make decisions about client management. Edwards,

Jones, Carr, Braunack-Mayer, and Jensen, (2004) found there were interplays of the

different types of reasoning utilized by physiotherapists when dealing with a case.

These findings were somewhat different from earlier findings that tend to point to an

isolated approach of the clinical reasoning process utilized by clinicians whilst

encountering a case. Various theories have implied that patterns of clinical reasoning

vary remarkably between expert clinicians and students or novice clinicians (Jones

& Rivett, 2004). Clinical practitioners have confidence in that pattern recognition is

possible only with an accurately systematized knowledge and massive clinical

experience. This implies that inexperienced students and novice clinicians hardly use

pattern recognition in their clinical practice. The general hypothesis is that novice

clinicians, including student physiotherapists just use hypothesis testing clinical

reasoning model more frequently (May, Withers, Reeve, & Greasley, 2010).

3.2 Factors affecting Clinical reasoning

Wimmers and Kentkowski (2016) stated that one could interpret how

clinicians make decisions in the complex and thought-provoking environment of the

health care system is to look beyond science or the empirico-analytical dimension of

seeing things. Novice clinicians such as physiotherapy students encounter clinically

ill-defined cases for the first time and therefore tend to use a clinical reasoning

model known as the Hypothetico-Deductive reasoning. This form of reasoning is a

vastly biomedical model of rationalizing which requires acquirement of cues and

inferences, interpretation, and evaluation of hypothesis (Tan, Ladyshewski &

Gardener, 2010). Other forms of clinical reasoning found in literature include:

ethical reasoning (Swisher, 2002), collaborative reasoning (Thornquist, 2001),

interactive reasoning (Fleming, 1991), procedural reasoning and diagnostic

reasoning (Croskerry, 2009).

The context in which clinical reasoning occurs plays an important role in the

process of clinical reasoning. Higgs and Jones (2000) itemized six elements that

have effect on the process of clinical reasoning. These include the personal context

of the client, the unique multi-faceted context of the client clinical problem, the

specific context of healthcare for the client, the wider health care environment,

knowledge fit, and the personal and professional framework of the clinician.

16

According to Higgs and Jones (2000), the personal context of individual clients

which integrate factors such as their cultural, work, and socio-economic background

shapes their awareness, values and expectations in relation to their clinical problem.

In relation to Higgs and Jones (2000) elements that affect clinical reasoning, one can

imply that Pacific culture and societies will have some effect over student’s way of

thinking and decisions.

According to Higgs and Jones (2000), the unique multifaceted context of the

client’s clinical problems simply explains the confusion or contradictions that can

arise from flawed, unreliable, or even wrong information. Another element that

affects clinical reasoning is the context of healthcare the client is presenting from.

Clients can present from clinics, public health promotion activities, community

settings, in the hospital wards or from the sports field. Even though the range of

context is diverse, the goal is on the health of the people. However, the context does

influence the nature of reasoning made and impacts on the decision.

Physiotherapist’s and other healthcare clinicians need to be aware of the

wider health care environment from which they operate. These include socio-

economic issues, cultural and traditional beliefs as well as human behavior. Another

critical factor that affects clinical reasoning is the knowledge explosion (Higgs &

Jones, 2000). It requires clinicians to be up to date with current knowledge and

insights into the conditions that they encounter. The dynamism of information

propelled through the rapid development of information technology necessitates

clinicians to be in advance with the knowledge as this directly affects clinical

reasoning and practice as a whole. An important element that affects clinical

reasoning is the clinician’s personal and professional framework under which they

operate. The term professional implies a qualified health care provider who

demonstrates professional autonomy, competence, and accountability (Higgs, 1993).

Clinicians unvaryingly utilize most of the clinical reasoning strategies in

their daily practice to inform their therapeutic conclusions (Higgs & Jones, 2008).

With physiotherapy students, however, these clinical reasoning strategies are often

being applied for the first time with novel clinical cases. The prospect for clinical

reasoning errors at this stage of practice development is, therefore, common

(Boshuizen & Schmidt, 2008). Consequently, strategies which support

17

physiotherapy students to enhance the consistency of their clinical reasoning and

metacognition are critical for entry level competence and work readiness.

3.3 Assessing clinical reasoning

Assessment of clinical reasoning is always a challenging issue. Decision

making is a cognitive phenomenon and therefore difficult to measure objectively.

Charlin, Bordage and Van der Vleuten (2003), researched and appraised the

assessment tools that were commonly used in the assessment of clinical reasoning in

the health sciences. These included the multiple choice questions (MCQ), viva or

oral examinations, Objective Structured Clinical Examination (OSCE), the Overall

Evaluation Grid, and observations of actual student practice. The researchers tried

to analyze the advantages and shortfalls of each and every tool they had assessed

(refer to Table 1). They tried to stipulate the strengths and suitability of each tool in

its capacity to psychometrically assess clinical reasoning in a reliable manner.

Table 1. Assessment of tools used in the assessment of clinical reasoning taken from

Deschenes et. al, 2011.

OVERVIEW OF TOOLS USED TO ASSESS CLINICAL REASONING

INCLUDING PROS AND CONS OF EACH.

Tool Uses Pros ConsOverall

Evaluation Grid

List of criteria

and behaviors to

be observed by

an outside

observer.

Comprehensive

assessment. Good

face validity for

evaluation clinical

competency.

Minimal items

that evaluate

clinical

reasoning.

Multiple Choice

Questionnaires

Assesses many

students and

includes a broad

spectrum of

knowledge.

Assesses

knowledge of

factual data and is

easy to score

Does not

differentiate

between novice

and expert and

does not assess

problem-solving.

Oral Examination Interview Provides a more

joint measurement

of knowledge,

Personal

attributes of

student can

18

skills and

abilities.

influence results

(e.g. anxiety or

verbal fluency)

Objective

Structured

Clinical

Examination

Simulated

situations with an

outside observer.

Evaluation grid

with predefined

expected

answers.

Effectively

evaluates the

clinical approach

through direct

observation. Good

inter-rater

reliability.

Only evaluates

observable

behavior not

clinical

reasoning.

Key Elements

Review

Written exam

that includes

clinical

situations.

Able to assess

decision making

ability with many

clinical cases.

Time required to

complete. High

number of cases

required to

ensure fidelity.

Assessment of

Authentic

Situations

Presents a task to

the student

involving the

integration of

knowledge

acquired.

Allows the

student to

understand and

solve a common

real life problem.

Time required to

complete. Time

required to

correct.

The researchers concluded that a tool that offered a more ambiguous

platform from which students were to clinically reason from, were missing or

vaguely present in the tools currently in use. To mirror and add specificity to

authentic clinical practice, the assessment tools needed to be able to assess clinical

reasoning in complex situations with high degree of uncertainty, less time

consuming to administer and mark. They recommended the SCT as a tool that was

able to offer a lot of what was being seen as an ideal clinical reasoning assessment

tool. The SCT therefore seems to be one of the proven legitimate assessment tools

for the analysis of clinical reasoning.

19

3.4 Theoretical framework

The script concordance test (SCT) which is the assessment tool identified

and used in this research for clinical reasoning assessment is a product based on the

‘Script Theory’. The Script theory tries to explain how the human mind understands

real life events and how this capability can become so effortless (Charlin,

Boshuizen, Custers, & Feltovich, 2007). It assumes that networks of cognitive

structures in the brain are formed when repeated experiences with real life situations

are encountered. The frequency and pattern of the events lead to formation of

structures that identify activities with similar patterns. The information structures are

stored and can be utilized to identify similar scenarios. Therefore scripts can be

described as goal directed adapted to perform tasks efficiently (Charlin et. al, 2007).

Any exposure to activities will result in the development of scripts that can be stored

to be utilized in future activation. The script is further enhanced with repeated

exposure to similar events. The Scripts theory method of reasoning is distinct from

the Hypothetico-deductive method.

The SCT is used in health sciences education to assess a specific aspect of

clinical reasoning: the capacity to interpret clinical information under conditions of

uncertainty (Lubarsky, 2013). Uncertainty is a normal clinical presentation in which

the information gathered is usually wide open therefore depends on how the

clinician interprets and acts upon this interpretation. It is highly important that the

clinician’s choice of action is one that is the most appropriate. This basically defines

clinical reasoning. The illness script and the Hypothetico-deductive model of clinical

reasoning are the two main reasoning models used by clinicians (May, Withers,

Reeves, & Greasely, 2010).

The Hypothetico-deductive model of reasoning remains the most enduring

model of clinical reasoning in both medicine and health science (Edwards et. al,

2004). This model of reasoning was derived from a cognitive science perspective. In

the Hypothetico-deductive method, the clinicians gather and study the initial cues

(information) from or about the client. From those cues, possible hypotheses are

generated. This formulation of hypotheses is followed by an ongoing analysis of

client information in which more data are gathered and interpreted. As client

examination continues, hypothesis formulation or negation is created as more and

20

more information which serves to rule out or support the generated hypotheses are

gathered. The hypothesis that is best well supported by the information and cues

from the clients becomes the confirmed one.

Figure 1. Relationship between key steps in the clinical reasoning process and the

format of SCT items (adapted from Lubarsky et al. 2009).

In clinical practices such as physiotherapy (as in medicine), Hypothetico-

deductive reasoning aims, within the limitations of available standards, to validate

information or data acquired from the patient through measurement in a reliable

manner (Edwards et.al, 2004). Clinical data gathering and acceptance or elimination

starts broad and then narrows down to the most supported hypothesis based on the

information collected from the client. This framework is utilized in this research

through the processes undertaken by the student in order to arrive to a decision that

is most common likened to the majority in the reference score.

The Script theory on the other hand, also rooted in cognitive psychology, is

an alternative clinical reasoning model which suggests an explanation of how

information is stored in the human mind and retrieved to influence individual

interpretation of objects and events (Schank & Abelson, 1997). It proposes that

when clinicians are faced with clinical problems, they activate sets of knowledge

that are gathered and reinforced through experience and exposure, known as illness

scripts to comprehend the situation and come to clinical decisions. These scripts are

used daily in clinical practice and are refined with experience.

21

This research is guided by the analytical-empirical-positivist-quantitative

paradigm. The analytic part of the research is reflected by the isolation and

assessment of scripts organization in physiotherapy students as a component of

clinical reasoning. The empirical aspect of the study is based on the ability of

students to recall and utilize information gained through prior experience on client

encounters to solve the cases they will be assessed upon. The positivist aspect is

based on the fact that past clinical experiences and information acquired as a result

of exposure will help students solve the cases they will be assessed on the SCT. The

quantitative aspect of the research is grounded on the fact that clinical reasoning,

even though is a cognitive process, can be indirectly quantified and analyzed using

the script concordance test tool. The analytical paradigm exists on the notion that if

something exists, it can be measured. Even though clinical reasoning is a cognitive

process, based on the analytical paradigm, the SCT is utilized to assess and quantify

an aspect of this cognitive process (Roberti I, Roberti II, Pereira II, Porto III, &

Costa, 2015).

Hypothetico-deductive and knowledge organization in scripts and pattern

recognition may be used interchangeably (Higgs & Jones, 2008). Experienced

clinicians may use pattern recognition and illness scripts in clinical reasoning

whereas novice clinicians and students often revert to the Hypothetico-deductive

model of clinical reasoning in solving a case (Higgs & Jones, 2008). Student’s

likelihood to use the hypothetico-deductive reasoning may be due to the fact that

they have not seen enough clients to formulate a strong information base from which

to draw from. Experienced clinicians may also revert to the usage of the

Hypothetico-deductive model when faced with a client coming in with an unfamiliar

presentation. This signifies that a strong information base and familiarity is required

for the use of illness scripts to diagnose a case.

While Physiotherapists tend to use more of the hypothetico-deductive model

or illness script, occupational therapists commonly use narrative reasoning.

Narrative reasoning is a client centered reasoning approach in which the clinician

listens to all the client information and strives to understand the uniqueness of every

case that is presented (Cruz, Careiro, & Pereira, 2014). Narrative reasoning is used

to try and understand the illness experience or elaborate how physiological changes

have brought about the physical disabilities presented by the client (Mattingly,

22

1991). Narrative and the hypothetico-deductive reasoning process represent two

contrasting school of thoughts. Hypothetico deductive reasoning is based on the

knowledge the clinician has while narrative reasoning is based on the interpretation

and sensationalizing the information presented by the client during the encounter.

The two cognitive oriented models of script theory and hypothetico deductive

reasoning when taken together are referred to as ‘diagnostic reasoning’ (Edwards et.

al, 2004). This establishes the fact that in the diagnosis of a client condition, a good

knowledge base is a pre-requisite on the clinician receiving the information that is

presented. In physiotherapy a good knowledge base to inform the reasoning

processes of models such as the hypothetico-deductive reasoning consists of

biomedical sciences such as anatomy, physiology, pathology, biochemistry,

microbiology, and therapeutic sciences.

Figure 2. Summary of the relationship between knowledge and reasoning paradigms

with clinical reasoning strategies (adapted from Edwards et.al, 2004).

The reasoning paradigm of which the hypothetico deductive reasoning is a

popular model is clearly clinician centered (Cruz, Careiro, & Pereira, 2014). The

level of the clinician knowledge which has implications on how the data from the

client is perceived and interpreted is much more significant than the client

presentation. Therefore, a pre-determined management which have been successful

23

in other similar clients would be taken as the ideal choice of line of management for

all such similar conditions (Cruz, Careiro, & Pereira, 2014). This is very distinct

from the narrative reasoning which utilizes the interpretive paradigm. Narrative

reasoning is client centered whereby the presentation of every client is taken into

account and interpreted to shape the management that is unique to every particular

case.

In summary, the literature reviewed identifies numerous support to the

emphasis on training of clinical decision making as a skill that can be developed

provided the other factors that contribute to its development are taken care of.

Factors such as basic knowledge base, socio-economic issues, and background do

have effects on the decision making capability of clinicians. The hypothetico-

deductive model of clinical reasoning is re-enacted in the process of undertaking the

script concordance test designed as the tool for this study

24

Chapter Four – Methodology

Introduction

The chapter explains the methods undertaken to conduct the research. Firstly the

quantitative approach used in assessing a cognitive phenomenon is described

followed by explanation of action research of which this study is an example of.

Sampling, the tools used and its implementation procedure is outlined in the

following paragraphs.

4.1 Quantitative approach

Clinical reasoning is a cognitive skill that cannot be readily quantified.

Reasoning is a cognitive phenomenon and therefore cannot be measurable. This

study aims to utilize the quantitative approach by measuring the direction and

intensity of the decision made by clinical students upon diagnosing a presenting

problem.

The 5 point anchor likert scale used to measure the direction and intensity of

the clinical decision making enables to quantify the uncountable decisions. Once the

decision is transformed into the scale, it can then be quantified and measured. The

SCT is an excellent tool to use when trying to quantify clinical reasoning. Once

quantified, analysis can then be conducted.

4.2 Action research

The term action research was first used by Kurt lewin in 1946 (Duffield,

2017). It describes social research that combines formulation of theory and creating

a change through the researcher’s action on or within the social system. It involves

creation of new knowledge as well as initiating real change through action that

involves a continuous cycle of planning, acting, observing and reflecting (Lewin,

1946). Put simply, the action researcher enters a situation and attempts to deliver

change and monitors the results (Collis & Hussey, 2009; Lewin, 1946)

This research takes the form of an action research in that while it aims to

establish knowledge on the level of clinical reasoning amongst physiotherapy

students, the identification of an assessment tool in the form of an SCT as well as

information gathered will be used to help improve the curriculum. The results from

25

the study will determine steps that will be taken to help improve clinical education

in physiotherapy students in Fiji.

A challenge with action research is the balance that needs to be maintained

between the role of the researcher as a researcher and the researcher’s role in the

organization (Duffield, 2017). In this research, the participants are the students of

the researcher. However, measures were put in place to ensure the relationship had

no effect on the results of the script concordance test. In the case of this study, this

balance was achieved through the masking of participant identification details.

Students were not asked for any form of identification on their script concordance

test answer sheets.

Action research was a suitable choice for this research as the result will

influence the department of physiotherapy and the university by way of providing a

feedback that aims to improve the quality and outcome of trained physiotherapists.

4.3 Sample

The study population was the physiotherapy undergraduate years 3 and 4

students from the Bachelor of physiotherapy program. The Bachelor of

physiotherapy program at the Fiji National University is a 4 year degree program.

Convenience sampling was used to recruit the 41 participants from the study

population. The sample size was derived from a calculation to yield a result that

would have a 95% confidence level at a margin of error set at 5. Convenience

sampling was used as the Fiji National University’s physiotherapy students were

available to the researcher and all students were invited to participate.

The Script Concordance Test (Appendix 1), a tool used for assessing clinical

reasoning that was identified from the literature review, was used to assess clinical

reasoning in participants of this study. A total of 41 physiotherapy students who

have read and signed the consent for participation (Appendix 2) into the study were

the participants. Since the researcher was a lecturer of the student participants, to

ensure details that would identify the students were concealed, demographic details

of neither the participants nor the expert clinicians were collected in the test. Even

though this limited the information about the participants, it did ensure that identity

of every participant’s remained unknown. Seventeen clinical vignettes were drawn

26

from the five physiotherapy specialist domains of musculoskeletal, neurology,

cardiorespiratory, gerontology, pediatrics and women’s health. In line with the

recommended structure of the prescribed assessment tool, the SCT is divided into 3

sections with each clinical vignette having 3 hypotheses options for diagnosis. New

information were then added to instigate the clinical reasoning process. The second

part presented a new clinical finding e.g a physical sign, pre-existing condition,

imaging study or lab result, while the third part of the case scenario was a five point

Likert scale that captured the effects of the newly added information on the

participant’s initial hypotheses.

The participant must decide what affect the new clinical finding in part 2,

had on the information or decision given in part 1 and must note the direction

(positive, negative or neutral) and intensity in part 3. The effect of the new

information on the given option was scaled on a -2 to 2 continuum. For this SCT,

each clinical vignette contained 3 items. There were a total of 51 items. The SCT

were first given to 13 expert Physiotherapists where the reference scores for each

item was established. In the SCT construction, any number of reference panel above

10 was required to achieve an acceptable reliability and correlation between samples

and whole set of panel members (Gagnon, Charlin, Colletti, Sauve, & Van der

Vleuten, 2005). A total of 17 cases with 51 questions for one hour of testing were

used in order to reach the Cronbach alpha values of 0.80 or higher (Gagnon, Charlin,

Colletti, Sauve, & Van der Vleuten, 2005). The SCT constructed for this research

satisfied all the requirements for such a test to be valid and reliable.

4.4 Script Concordance Test:

An extensive literature search was conducted via the University of the South

Pacific e-library on a tool to be used for assessment of the Script Concordance Test.

The EBSCO database was used to search for e-journals with the key words of

‘clinical reasoning’, ‘assessment’ and ‘physiotherapy’ used to yield search results.

Construction of the SCT to be used for the study followed the recommendations

from the literature search.

Development procedure of the SCT included the following steps (Deschenes,

Charlin, Gagnon, & Goudreau, 2011);

27

(1) The assessment matrix was based on the clinical conditions that were

frequently encountered by the physiotherapy students during their clinical

attachments to achieve a good representative sample of common clinical cases.

Table 2. A Clinical vignette with the three items.

Clinical vignette:A 21 year rugby player presents with painful knee on the medial aspectIf you were thinking of New information Your hypothesis is

-2 = greatlyweakened,-1 = slightlyweakened,0 = no effectonhypothesis,1 =strengthened2 = greatlystrengthened

Medial meniscus Knee MagneticResonance Imagingshowed no abnormality

MedialCollateralligament strain

Valgus stress test ispositive

Fracture ofmedial aspect ofknee

X-ray shows no bonyabnormality

Clinical educators of the BPT program, representing the main sub-disciplines

of physiotherapy (Cardiorespiratory, musculoskeletal, neurology, pediatric,

women’s health, and gerontology) provided the information on the proportion and

representations of the sub-disciplines vignettes into the SCT. The three test items

were chosen to reflect authentic probable diagnosis to the clinical cases that were

presented. This encapsulated factors from biomedical and physiotherapy issues that

were rife in the common cases encountered in the clinics by both physiotherapy

students and expert physiotherapy clinicians.

(2) To disclose whether the students’ unfamiliarity with the SCT format of

items would affect their reasoning and choices, trial sessions were conducted with

demonstration on how to answer the test. These demonstrations confirmed

28

commitment of the students in the proposed cognitive processes. Changes in the

format or phrasing of the clinical vignettes were not indicated due to time

constraints; the trials did, however, reveal the necessity for high-quality test

instructions.

(3) The final version of the SCT was constructed, composing of 17 case

vignettes and 51 test items to create a sample large enough for the content to be

tested. Previous studies (Charlin, Tardif, & Boshuizen, 2000) indicated that an SCT

needs about 50–60 test items to achieve a reliability (Cronbach’s α) of 0.80 or more.

The final version of the SCT satisfied the prescribed conditions outlined in the

literature.

(4) To establish the answers, the test was completed by the reference panel

made up of 13 physiotherapy expert clinicians. Based on previous studies (e.g.

Gagnon et al., 2005), a minimum of 10 experts was regarded as sufficient. Fifteen

expert physiotherapy practitioners were approached to participate; 13 agreed and

completed the test. The criteria for inclusion of clinician experts was that they are

currently practicing with more than 2 years of full time clinical work. Experts of the

sub-disciplines of physiotherapy was impossible to recruit as the physiotherapy

profession in Fiji have not developed specialization into the different streams. This

can be seen as a hurdle right now until such time the profession is ready to develop

specialization within its service arm.

(5) In addition to the test itself, a short feedback was obtained from the

expert clinicians about the SCT format of test items, ambiguity of the vignettes and

the representativeness of the common physiotherapy clinical cases. Their feedback

was taken in as a form of moderation of the test and relevant changes were done to

the existing test tool.

4.5 Implementation procedure

The data collection process was taken with the following procedure:

1. The SCT was first undertaken by 13 expert physiotherapy clinicians

from whom the normative reference for the test was derived.

29

2. Bachelor of physiotherapy year 3 and 4 students were informed of the

study and its benefits for them and the program. Benefits for the students will

include an improvement in the clinical education of the program which will directly

benefit them, their colleagues, and the profession of physiotherapy. They were

clearly informed that their participation was based on their volunteerism and that

there were no repercussions to their academic outcomes. Participants could pull out

at any time they wished during the process of data collection. They were also

informed of what was expected of them in undertaking the SCT.

3. Students who had volunteered to be participants for the research were

then informed of the date and venue of the test.

4. On the test day, volunteer participants first signed the consent forms

before the explanation of the test procedure was made.

5. After taking the test, the scripts were numbered from 1 – 41 and

stored in sealed envelopes for analysis. Year 4’s scripts were numbered from 1 – 11

and Year 3 scripts were numbered from 12 – 41 to indicate the two cohorts.

4.6 Analysis of SCT

Randomly chosen, 13 expert clinicians were approached to complete the test

individually and their answers were used to develop the scoring key or norm

reference for the students test (Charlin, 2002). The answer (5 point likert scale) that

majority of the experts picked was given a value of 1. Answers not picked by the

experts were given a value of 0. Other answers were given a proportionate value

(equal to the number of experts who picked the answer divided by the modal value

for the question). For example, if 9 out of the 13 experts pick +2, then +2 would be

worth 1 (9÷9), If 2 expert picks +1 then +1 would be worth 0.2 (2÷9), if 1 expert

picks 0, then 0 would be worth 0.1 (1÷9), -1 will also be worth 0.1 if 1 expert chose

it and -2 would be worth 0 since none of the experts chose it as the answer.

Participants (physiotherapy students) then took the same Script Concordance

test and their score for each item was added to give a total score for the test (each

clinical vignette had a maximum of 1 and a minimum of 0 for the three items). The

total score for the test was divided by the number of questions (51 for this SCT) and

multiplied by 100 to derive a percentage score for the test. The standard setting was

30

used where the pass mark was determined by one standard deviation from the mean

of the respective cohort (Year 3 and Year 4) percentage scores (Charlin et. al, 2010).

When comparison was done on student scores against clinician scores, a ‘good’ level

of clinical reasoning was defined as scores below the clinicians mean by 2 standard

deviations. An excellent score was defined as those falling within 1 standard

deviation of the clinicians mean score.

SCT data was further analyzed using the IBBM statistical package for the

social sciences (SPSS) software version 24 for descriptive analysis, p values,

correlations, graphical analysis, and display of data.

In summary, although clinical reasoning is a qualitative occurrence, it can be

assessed quantitatively using the Script Concordance test as a tool. The central

requirement for utilization of the tool is the requirement for a group of experts to

form and provide the reference answers which the student’s scores can be referenced

to.

31

Chapter Five – Findings

Introduction

This chapter explains the findings of the study. The results are presented in themes

of the test, analysis of expert responses which forms the reference scores and student

scores which is further broken down into class referenced, norm referenced, and

scores by physiotherapy specialty streams.

1. Script Concordance Test

According to Charlin, Boshuizen, Custers, and Feltovich (2007), scripts are

made up of networks between illnesses, clinical features and management options.

Health professionals advance through the assessment and management options of a

clinical condition with relevant knowledge networks (scripts) in mind. They actively

use them to constantly make judgments on the effect that each new piece of

information has on the status of the hypothesis or option (Charlin et. al., 2007).

Script concordance testing (SCT) is based on the principle that the multiple

judgments made in these clinical reasoning processes can be investigated and their

concordance with those of a panel of reference experts can be measured. This

provides a tool for assessing clinical reasoning (Charlin & Van der Vleuten, 2004).

SCT is not meant to replace other commonly used clinical competence

assessment tools such as OSCEs (Objective Structured Clinical Examinations) or

rich-context written cased study examinations. It complements them in strategies for

assessing comprehensive clinical reasoning. Its format allows examiners to explore a

facet of clinical reasoning that is usually excluded from traditional medical

assessments but frequently faced in daily clinical practice: reasoning in situations for

which there are no clear correct answers (Fournier, Deemster, & Charlin, 2008).

Forty-one out of forty-three participants consisting of 3rd and 4th year

physiotherapy students at the Fiji National University successfully completed the

Script Concordance Test (95% response rate). Two participants did not turn up for

the test citing personal reasons for being unable to attend the test sessions. The

results of the SCT are presented in 2 headings: 1. Analysis of expert scores, and 2.

Analysis of student scores.

32

2. Analysis of Expert Scores

Response rate from the expected number of expert physiotherapists was

100% (n=13). The mean score for their SCT was 78% with a standard deviation of 5

(mean=78% ± 5). The reference mark for each item was established from the expert

scores. The reference mark was used to analyze the responses of the students SCT

scores.

Table 3. SCT Reference key from expert scores

Clinical

Vignette

number

(n=51)

Score Frequency (n=13) Item marks (0.0 – 1.0)

-2 -1 0 1 2 -2 -1 0 1 2

1.1 1 3 4 3 2 0.25 0.75 1 0.75 0.51.2 0 0 0 4 9 0 0 0 0.4 11.3 7 0 4 2 0 1 0 0.57 0.29 02.1 0 1 5 5 2 0 0.2 1 1 0.42.2 1 2 6 3 1 0.17 0.33 1 0.51 0.172.3 0 0 1 8 4 0 0 0.13 1 0.53.1 0 3 6 3 1 0 0.5 1 0.5 0.173.2 1 6 5 0 0 0.17 1 0.83 0 03.3 0 0 1 1 11 0 0 0.09 0.09 14.1 4 5 1 2 1 0.8 1 0.2 0.4 0.24.2 1 2 0 4 6 0.17 0.33 0 0.6 14.3 5 3 4 0 1 1 0.6 0.8 0 0.25.1 0 5 3 1 4 0 1 0.6 0.2 0.85.2 4 7 2 0 0 0.57 1 0.29 0 05.3 0 2 0 3 8 0 0.25 0 0.38 16.1 0 0 0 0 13 0 0 0 0 16.2 5 4 0 3 1 1 0.8 0 0.6 0.46.3 0 3 4 2 4 0 0.6 1 0.5 17.1 0 1 3 7 2 0 0.14 0.43 1 0.297.2 1 0 0 2 10 0.1 0 0 0.2 17.3 6 4 2 1 0 1 0.67 0.33 0.17 08.1 1 1 4 4 3 0.25 0.25 1 1 0.758.2 6 3 1 3 0 1 0.5 0.17 0.5 08.3 4 5 3 1 0 0.8 1 0.6 0.2 09.1 0 0 0 10 3 0 0 0 1 0.39.2 0 1 2 4 6 0 0.17 0.33 0.67 19.3 2 7 4 0 0 0.29 1 0.57 0 0

33

10.1 0 0 3 7 3 0 0 0.43 1 0.4310.2 3 0 5 3 2 0.6 0 1 0.6 0.410.3 4 3 4 1 1 1 0.75 1 0.25 0.2511.1 0 0 0 2 11 0 0 0 0.18 111.2 1 0 1 10 1 0.1 0 0.1 1 0.111.3 0 4 5 3 1 0 0.8 1 0.6 0.212.1 0 0 0 3 10 0 0 0 0.3 112.2 1 0 3 7 2 0.14 0 0.43 1 0.2912.3 0 7 4 2 0 0 1 0.57 0.29 013.1 0 0 0 2 11 0 0 0 0.18 113.2 7 1 0 4 1 1 0.14 0 0.57 0.14

3. Analysis of student scores

Year 3 and Year 4 physiotherapy students demonstrated competent

diagnostic clinical reasoning at a level that was more than half to those of the experts

in the field. Year 3 students demonstrated a mean score of 59.32% ± 8.03, while the

fourth years scored a slightly higher score of mean = 64.97% ± 10.17 to the

reference norms derived from the experts.

3.1 Clinical Reasoning class referenced.

In recognition of the effects of exposure from the hours of clinical practice to

the development of the illness scripts, the cohorts pass marks were also class

referenced. The pass mark was set at 1 standard deviation from the respective class

mean (64.97% ± 10.17, and 59.32% ± 8.03 for 4th and 3rd years respectively).

Table 4. Proportion of students with levels of CR class referenced.

Levels Good level of CR

Exposure Year 3 83%

Year 4 80%

Table 4 shows that a higher percentage of Year 3’s had scores that were

classified as ‘good’ level of clinical reasoning when referenced within the class

scores. Year 4’s recorded a lower proportion of students scoring within the ‘good’

level.

34

3.2 Clinical Reasoning Norm Referenced.

As defined earlier, a good level of clinical reasoning for this particular test was set at

57 for the year 4s and 52.8 for year 3’s. These are 1 standard deviation from the

class mean score (Table 5).

Table 5. Proportion of students with levels of CR norm referenced.

Levels Good level of CR Excellent level of CR

Exposure Year 3 63.3% (n=19) 3% (n=1)

Year 4 72% (n=8) 27% (n=3)

Table 5 shows a higher proportion of year 4’s in the good and excellent levels when

referenced to the normative scores derived from the expert clinicians.

3.3 Clinical Reasoning by Specialty areas

Assessment of the student’s clinical reasoning based on the physiotherapy

specialty areas demonstrated differences in levels of student clinical reasoning

according to the specialties as shown (Table 6, Figure 3) below.

Table 6: Student SCT scores by specialty areas

Specialty areas BPT03 BPT04Cardiorespiratory 57.5% ± 7.6 65.9% ± 9.5Musculoskeletal 58.3% ± 11.6 65.4% ± 10.2Neurology 59.9% ± 10.9 54.8% ± 8.2Pediatrics 63.5% ± 12.3 75.7% ± 10.7Women’s Health 54.7% ± 15.5 66% ± 10.9Gerontology 67.8% ± 19.9 66% ± 28.95

Table 6 shows the average clinical reasoning scores of year 3 and 4 students on the

physiotherapy sub-disciplines. Year 3’s had highest scores on gerontology whilst

35

scoring lowest on cardiorespiratory. Year 4’s scored the highest in pediatrics and

lowest on neurology.

Figure 3. Result (mean ± SD) of student (BPT03 n=30, BPT04 n=11) SCT scores

by the 5 specialist areas represented within the clinical vignettes.

Table 7. Descriptive data for the SCT results.

n Range Minimum Maximum Mean Std.Deviation

Variance

BPT04 11 32.70 43.80 76.50 64.9727 10.1744 103.520BPT03 30 32.10 41.30 73.40 59.3200 8.02631 64.422Experts 13 25.70 65.10 90.80 77.6846 6.6196 43.820Valid N 11

Table 7 shows that mean, range, minimum, maximum, and standard variation of

students and expert clinician scores.

0102030405060708090

100m

ean

(SD

) sco

res (

%)

Physiotherapy specialist area

Script Concordance Test scores by specialist areas

BPT03

BPT04

36

Figure 4. Script concordance test results with reference panel test result BPT03 had

30 participants, BPT04 had 11 and there were 13 expert clinicians.

3.4 Correlations

Pearson’s correlation test showed there was a negative relationship between

the BPT04 clinical reasoning scores when correlated to both BPT03 and the clinical

expert panel scores. The nature of this relationship was not significant (r value = -

0.35, p value = 0.295). There was a positive relationship between the BPT03 scores

and the expert panel. However, the nature of the relationship was insignificant (r

value = 0.256, p value = 0.398) (refer to table 7 below).

37

Table 8. Pearson’s correlations and significant levels for relationships of thestudents and expert SCT scores.

CorrelationsBPT4 BPT3 Clinician

BPT4 PearsonCorrelation

1 -0.347 -0.203

Sig. (2-tailed) 0.295 0.550

N 11 11 11BPT3 Pearson

Correlation-0.347 1 0.256

Sig. (2-tailed) 0.295 0.398

N 11 30 13EXPRT Pearson

Correlation-0.203 0.256 1

Sig. (2-tailed) 0.550 0.398

N 11 13 13

3.5 Normal distribution of scores

BPT scores were equally distributed with majority scoring within 2 standarddeviations from the class mean (refer to Fig. 6).

Figure 5. Normal distribution curve of BPT03 SCT scores.

Year 4 scores were slightly skewed to the upper scores with an outlier on the lowerside of the curve (refer to Fig. 7)

38

Figure 6: Normal distribution curve of BPT04 SCT Scores.

Expert score frequency were slightly skewed to the higher score side of thedistribution curve with an outlier on them lower side of the distribution curve (referto Fig. 8)

Figure 7. The normal distribution curve of expert SCT scores.

39

Diagnostic clinical reasoning concordance of physiotherapy students were

similar to the panel of expert clinicians used in this study. Diagnostic and narrative

reasoning are meant to be reinforced by different research paradigms: diagnostic

reasoning reflecting a positive or quantitative approach, and narrative reasoning an

interpretative or qualitative approach (Jones, Jensen, & Edwards, 2008). This

research is grounded by a positivist approach aimed at quantifying or measuring a

qualitative phenomenon of cognition and metacognition. Student’s results when

compared for similarity with expert clinicians suggest that the current clinical

education model used is adequate enough to prepare professionals in terms of

diagnostic clinical reasoning at least. It is clear that experience through exposure to

clinical cases they will get upon starting work post-graduation, will facilitate the

leverage and reinforcement of their illness script network.

In Summary, the scores of physiotherapy students in this particular cohort

were not significantly different from the expert panel scores. This shows that the

level of clinical reasoning demonstrated by the students in this assessment were

somewhat similar to physiotherapists who were practicing in the field.

40

Chapter Six – Discussion

Introduction

This chapter discusses the findings from the study and aims to provide linkages and

justifications as to the possible explanations of the outcome of the research.

Breakdown of results and justifications are provided followed by discussions on the

study limitations. The chapter ends with the implications the findings of this study

has on shaping the current clinical education in physiotherapy.

Clinical reasoning norm referenced

The result points to the inference that there are no significant difference in

the level of clinical reasoning between the students and experts scores (Table 5).

Once can draw that the relationship between increased total hours of student clinical

exposure to authentic practice and the resulting level of clinical reasoning may not

be a is not a positive one. Virtually, it may suggest that the program is reasonable

with the current duration of clinical practice blocks it offers students as an

opportunity to practice. At the moment the final year students undergo four blocks

each containing six weeks per block while the third years (BPT03) are clinically

exposed to three blocks each containing six weeks per block for their clinical

attachment. In comparison, the expert clinicians are on clinical exposure for 8 hours

of the day 5 times per week. Since there is no significant difference in the levels of

clinical reasoning of the 3 groups, it may suggest that other factors that affect

clinical reasoning such as information permanency in student’s illness scripts, basic

individual student cognitive capacities, quality of clinical education supervision,

environment of exposure, and maturity levels of students may be playing a

significant role and must be addressed in order to achieve better clinical reasoning

levels.

A basic foundation of quality of illness scripts is the access and exposure to

basic knowledge that informs it. The illness script is classified as a diagnostic

reasoning process which heavily relies on the clinician’s knowledge base to form a

proper analysis of client presentations (Cruz, Careiro, & Pereira, 2014). Since the

process and model of reasoning is clinician centered, it is the role of the training

institution to properly train clinicians with the knowledge they will need to be able

41

to reason out sufficiently. The FNU, being one of the very few health professional

educators in the South Pacific islands should prioritize to ensure that biomedical

knowledge of conditions are properly taught to students. Having a well-structured

network of the illness scripts will greatly assist students in retrieving a frequently

engaged metacognitive pattern. This has implications on the structure and quality of

health professional programs offered. A need for quality assurance validation

process to assess integrity of the programs is warranted to assist the realization of

the graduate attributes students are capable of achieving as a result of engaging in

the offered program.

Physiotherapy functions on the basis of scientific based knowledge and

skills. Clinical education experiences provide students with opportunities to

investigate theories and facts learned in a classroom setting and to enhance skills

through client collaboration under the supervision of clinical educators (Casares,

Bradley, Jaffe, & Lee, 2003). The quality of clinical educators from which students

are coached and mentored is critical in the process of safeguarding that clinical

students are exposed to an environment that is conducive to development of their

knowledge and skills. From a training institution point of view, it is utmost

important that the curriculum and the materials used including human resources, in

the clinical training of professionals are of the finest quality. These include the

curriculum design, physical teaching materials, as well as clinical educators who

implement the program.

The result of this study may be interpreted from various viewpoints. From

the expert clinician’s point of view, it may reflect a reference level that is rather low

as it is not significantly different from a student level of clinical reasoning (Figure

4). It warrants a thorough review of the current clinical practices with indications of

the need for continuous professional development in the practice to ensure practice

and leveraging of clinical reasoning skills amongst clinicians. Circumstances that

require activation and reflection of the clinical reasoning process will help to keep

and improve the current level of clinical decision making amongst clinicians. It can

be inferred from the study, that further improvements amongst clinician is required

and this may be achieved by the continuous activation of the clinical reasoning

process over and over again. Similar to most other competencies, clinical reasoning

must be regularly practiced vigorously and appropriately so that it is effortlessly

42

replicable. Activities that enhance clinical reasoning such as case discussions and

assessed or appraised practice sessions will be an advisable way in developing

problem solving skills of clinicians.

The practice, licensing and accrediting body of the physiotherapy profession

in Fiji is the Fiji Allied Health and Practitioners Council (FAHPC) that was

formulated in a decree of 2011. The purpose of the Fiji Allied Health Practitioners

council is to ensure that the quality of service and care is maintained. The council

must continue to play its function in seeking consistency of clinical competencies

from its professionals. Continuous professional development activities must be

demanded with implications in order for members to recognize its importance and

take meaningful actions in fulfilling this requirement. Through continuous regular

practice of such competencies as clinical reasoning, quality and strength of the script

as well as the practice can be assured

A key component in the development of clinical reasoning skills in students

is the harnessing of cognitive and metacognitive skills. Clinical reasoning is a

process that involves both cognition and metacognition (reflective thinking)

(Banning, 2008) and is dependent on a critical thinking ‘‘disposition’’ (Scheffer &

Rubenfeld, 2000). Clinical education goals must be targeted towards development of

such skills of students. Cognitive skills that enhance reasoning must also form a

critical part of clinical education. A strategy that has recently been supported by

evidence to show augmentation clinical reasoning skills is the use of simulations and

its technologies such as manikins or even through the use of simple to complex case

studies (Feingold, Calaluce, & Kallen, 2004). Studies conducted on undergraduate

nursing students had shown that critical thinking, clinical skills performance,

knowledge acquisition and self-reported levels of confidence were all boosted

following the use of simulation technologies such as human patient simulation

manikins (Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010). Technological

advancements such as the use of manikins, offers virtual and realistic clinical

practice environment to clinicians, who require frequent practice of their clinical

cognitive and physical skills. Practice in environment that closely resemble authentic

practice environment supports harnessing of decision making quality.

43

Another central key component of clinical reasoning is the reasoning ability

of the clinician. Since reasoning is a cognitive process, cognitive skills should be

harnessed and enhanced in students to assist in the development of student thinking

capacities. Whilst knowledge base is critical for proper reasoning, the clinician or

students ability to utilize the stored information is far more significant. The

knowledge of basic information may be likened to the accessibility of raw materials

for manufacturing. Whilst access to raw materials creates an opportunity to be

realized, how the raw materials are used is more imperative. Proper utilization of

available knowledge to assist students and clinicians to solve a case is important in

solving a case. Without the skill of correctly utilizing the information clinician or

students can access, clinical reasoning could easily become an erroneous exercise.

Clinical reasoning is a process of reflection and decision making. Reflection

is a process by which the clinician or student stops and thinks about his/her practice,

consciously analyzes the decision making and draws on theory and relate it to what

he/she does in practice (Chartered Society of Physiotherapy (CSP), 2016). It is

essential that fortification of this understanding to students is carried out throughout

the process of professional training. A clinical practice that lacks reflection can be

potentially misguided and ineffective. In reflecting through decision making, a

clinician will have an insight into what worked and what has not. The process of

reflection is an essential component of clinical decision making amongst clinicians.

Clinical reasoning is affected by various factors of the environment it is

being carried out in, or, by the clinician’s personality traits. A major factor that does

affect the ability to reason in students is their own personality factors and cultural

background. Culture plays an important role in influencing a person's learning

process and the skills that are learned (Ingalls, Hammond, Dupoux, & Baeza, 2006).

In the literature search conducted for this study, the Script Concordance test

was not a commonly utilized clinical reasoning assessment tool in physiotherapy

education. The common assessment tools found for psychometric assessment of

clinical reasoning include the generic ones such as the observation of authentic

practice, Delphi methods which entails a consensus from a panel, and generic tools

such as the MCQ’s and OSCE’s.

44

6.1 Limitation

The principal limitation is related to the small cohort of participants and

composition of panel. Fournier, Deemster, and Charlin (2008, p.5), stated that "The

basic idea behind SCT is to compare students' performance with a group of persons

who are legitimate representatives of the profession to which they wish to belong".

While the ideal clinical experts in the physiotherapy specialist areas are those that

have specialized skills, there are currently no specialization in physiotherapy which

provides a challenge to expert clinician recruitment. Physiotherapy practice in Fiji is

still on general practice where a clinician can see clients across the board without

specializing into a particular branch. The reference scores for the specialists in the

physiotherapy specialist area have really been taken from general practicing

physiotherapists.

In relation to the small cohort used for the study, although studies in many

domains have revealed the SCT to be both reliable and valid, they have always

included a relatively small set of items and candidates (Charlin, Tardif, &

Boshuizen, 2000). Carrying out the tests and then scoring it to a bigger number of

students will require a significant amount of the clinical educator’s time and effort.

To allow for ease of access by students and administering, the test is best made

available online. In utilizing online SCT, variations and use of additional materials

such as the use of slides can be added rather than just worded clinical vignettes. This

will also cater for students who are more visual and kinesthetic learners. Other

common limitations to the extensive application of the SCT are the difficulty in

recruiting the clinical experts who will be able to provide a fair scoring on which the

assessment of student scores will be based upon.

Gagnon et. al, (2005), had stated that for high stake examination, an expert

panel made up of ten members or more was required to produce a reference score

that would acquire acceptable reliability estimates. Recruiting the best professionals

of the required number who are legitimately suitable to be bestowed the title of

‘expert clinicians’ in their field of expertise would be a challenge to find, especially

in clinical environments that are challenging such as in the context of the South

Pacific region. Considering the difficulty in recruiting the right professionals for this

exam, getting the required number would be a challenge.

45

6.2 Implications for Physiotherapy Education

Despite this few limitations, the current study provided additional evidence

for the use of the SCT in physiotherapy education. The SCT is one of the

recommended valid tools that can be used for the assessment of clinical reasoning in

students. It is highly relevant to clinical situations where students are required to

make decisions under uncertainty resulting from limited information and cues from

the client. Whilst the other methods such as MCQ’s (Multiple choice questions),

OSCE’s (Objective structured clinical examination’s) and observations are more

commonly used in clinical education assessments, SCT provides an option that uses

comparison of similarity in clinical reasoning to a reference panel of clinical experts.

SCT can be clearly used as a measure of clinical proficiency rather than merely

analyzing the problem solving approach of clinical students. The script concordance

test is valid, reliable, standardized tool designed to meet these objectives (Charlin &

Van der Vleutin, 2004).

The result of this study points out that the current clinical hours used in the

physiotherapy curriculum was sufficient. It stresses the point that the quantity as

well as the quality of the clinical exposure is important in clinical education

programs.

In summary, the findings pointed out that an important aspect of clinical education

which needs reinforcement in the current curriculum; the need to monitor the quality

of clinical education. Satisfying the required hours was no longer adequate as the

quality of content of the hours seems to be a major factor.

46

Chapter Seven – Conclusions and Recommendations

This final chapter discusses the conclusions and recommendations as a result of the

findings to the physiotherapy curriculum at the Fiji National University as well as

the physiotherapy profession in Fiji. The objective of the recommendation is to

advice on possible changes that are evidence based.

The purpose of this study was to analyze the clinical reasoning of

physiotherapy students via a comparison of their diagnostic clinical reasoning levels

to those of a panel of expert physiotherapy clinicians. The result of the outcome, will

indirectly give an indication of the efficacy of the current clinical education model

and structure via student clinical education competency, utilized by the Bachelor of

Physiotherapy program at the Fiji National University (FNU). As evidenced by the

results of this study, clinical reasoning level of physiotherapy students was good

without any significant difference to the reference normative data of the clinician

experts. This provided an indication that the quality of the current clinical education

curriculum is sufficient.

Amidst non-evidenced based assumptions regarding the level of clinical

reasoning in undergraduate physiotherapy students from FNU were graduating with,

the study has proven that there were no significant differences in clinical reasoning

of BPT students to those of expert clinicians within the profession. The study

recommends the current clinical education structure as it is resulting in clinical

reasoning that is not significantly different from clinicians. However, the

relationship lies within it contexts that increasing exposure to clinical practice, may

result in increased levels of clinical reasoning when defined upon its equivalence to

those of practicing clinicians. This reflection is a claim that can be justified based on

the results of the SCT conducted.

The mean for the expert clinician’s concordance level was the highest when

compared amongst the 3 groups – experts, year 4, and year 3 students. Even though

the difference is statistically insignificant, practically, measures that will assist in

continuous improvement of clinical reasoning in students should be a priority as

client safety that could potentially be risked by inefficient or poor clinical reasoning

should never be compromised. The study recommends that cognitive skills of

students must be harnessed during clinical education and continued into the

47

professional practice through activities such as case presentations or regular practice

audits. The physiotherapy professional body (Fiji Physiotherapy Association) can

also assist in ensuring continuous professional development of clinicians through

requirements for participation into activities that will enforce good clinical and

cognitive decision making.

The results of this study also justify and imply that whilst the current

structure of the clinical education program utilized by the BPT program is sufficient

to bring about a good baseline level of clinical reasoning in students before they

enter the workforce, there were differences in the levels of clinical reasoning

attained for the sub-disciplines of physiotherapy. Sub-disciplines such as neurology

and women’s health may need more attention to development of clinical reasoning

compared to the other areas of the service.

While script concordance testing has never been used in physiotherapy,

nursing or medical education in Fiji, it has been clearly documented as a valuable

tool for assessing clinical reasoning in medical schools elsewhere. Development of

more scenarios and items based on clinical physiotherapy practice areas and the

establishment of criteria for the optimal panel makeup will enhance the use of the

SCT in physiotherapy education in Fiji and the Pacific. The SCT will provide

physiotherapy educators with a reliable, standardized, and easier to administer and

grade method of assessing clinical reasoning skills in physiotherapy students under

situations that are ambiguous or have a high degree of uncertainty.

Finally, to my knowledge, this is the first Script Concordance Test done on

medical and health science students here in Fiji. The study has shown amongst the

qualitative analysis of clinical reasoning, that the assessment tool of SCT is available

and can be readily utilized by the BPT program to assess clinical reasoning in

physiotherapy students. It may be used as both a continuous and end point

assessment piece in clinical education. This could also be used for bench marking

standard competency the training institution will be required to live up to. In

summary, to ensure that graduates exit physiotherapy professional training ready to

make efficient and effective decisions that will uphold high standard of clinical

service and client care, it is imperative that clinical reasoning be assessed and

developed throughout the clinical training period.

48

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APPENDICES

Appendix 1: Script Concordance Test

Instructions:

The Script Concordance test aims to assess clinical reasoning using case studies (clinical vignettes).A brief clinical vignette is given on the top row of the table. The first column provides a relevantdiagnostic option. The second column provides the new information that is available after consideringthe probable diagnoses in column 1. The third column shows the scores you will use to assess theeffect the new information on column 2 has on your diagnosis from column 1. Please write on thespace provided in the third column, the scores which best describe the effect of the new informationon your diagnosis.

Clinical Vignette # 1

Clinical vignette:A 21 year rugby player presents with a painful knee on the medial aspectIf you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightlyweakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Medial meniscus X-ray shows no bonyabnormality

Medial Collateralligament strain

Valgus stress test is positive

Fracture of medialaspect of knee

X-ray shows no bonyabnormality

Clinical vignette # 2

Clinical vignette:A 59 year old lady is referred to Physiotherapy outpatient department with (L) shoulder pain

54

If you were thinking of New information Your hypothesis is-2 = greatly

weakened,

-1 = slightlyweakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Frozen Shoulder The lady is a knownDiabetic case.

Biceps tendinitis X-ray show no bonyabnormality

Labrum tear Slipped on anoutstretched arm

Clinical vignette # 3

Clinical vignette:56 year old man presents with pain and swelling of bilateral kneesIf you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightlyweakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Osteoarthritis Diabetic client

Gouty arthritis X-ray show no bonyabnormality

Septic arthritis White cell count isextremely high

Clinical vignette # 4

55

Clinical vignette:A 19 year old soccer player presents with a painful swollen ankle from last Saturday’s games

If you were thinking of New information Your hypothesis is-2 = greatly

weakened,

-1 = slightlyweakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Ankle sprain No history of trauma

Gouty arthritis Symptoms startedspontaneously overnight

Fracture No bony abnormalitydetected

Clinical vignette # 5

Clinical vignette:A 34 year old male presents with an acute low back pain

If you were thinking of New information Your hypothesis is-2 = greatly

weakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Muscle spasm Palpation shows no markedrigidity over spinal muscles

Nerve impingement Straight leg raise does notincrease symptom intensity

Arthritis x-ray shows over growth ofspinal bones.

Clinical vignette # 6

Mrs. Prasad calls the St. John ambulance because she woke up in the morning to find her 35-year-

56

old husband lying in bed confused, a left-side facial droop, and not moving his left arm and leg.Ambulance arrived and sees him lying in bed confused with slurred speech, left-side facial droopand left side-paralysis. They administer oxygen (O2) via non-rebreather mask at 12 L/min andstarted an IV of normal saline and transported to the Emergency Department on the ECG monitor.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Cerebrovascular accident(CVA)

CT Scan shows mass hemorrhageon MCA.

Hypoglycemia En route, the crew checks hisblood glucose serum level; it’s 5.4mmol/l.

Epilepsy He responds quickly to the glucoseand can answer questions and letsthem know that he has a pasthistory of epilepsy and hasn’t beentaking his medications recently.

Clinical vignette # 7

Jale is admitted in acute medical ward. His first symptoms included varying degrees of weaknessor tingling sensations in the legs which was symmetrical. Weakness and abnormal sensationsspread to the arms and upper body. These symptoms increased in intensity until certain musclescannot be used at all and, when severe, he is almost totally paralyzed.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Guillain Barre Syndrome(GBS)

The symptoms occurred 1 weekafter he had pneumonia

Spinal stenosis MRI result shows pressure onspinal cord.

diabetes Blood glucose level both randomand Fasting were within normallimits

57

Clinical vignette # 8

A 2 year old child presents to paediatrics physiotherapy with a lack of muscle coordination whenperforming voluntary movements (ataxia); overly tight muscles and exaggerated reflexes(spasticity); walking with one foot dragging; walking on the toes, a “scissored” gait; and muscletone that is too stiff.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Cerebral Palsy History of involvement at a motorvehicle accident a year ago

CVA CT scan results are negativemeningitis Blood test results are normal

Clinical vignette # 9

Tomasi is admitted in Acute surgical ward with paralysis at the T10 level sustained during acollapsed rugby scrum.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Spinal Cord Injury Felt sudden symptom during thegame

Spinal Cord Injury Pain felt gradually within 24hoursafter the game

Spinal fracture x-ray shows normal bony

58

alignment

Clinical vignette # 10

A 6 month old child cannot sit up unsupported, doesn’t respond to sounds, will not turn to youwhen you call her name.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Delayed Milestone Comes from a very poor familybackground

Cerebral palsy She is admitted with control of hernutrition which she responds topositively

Stroke CT scan results are normal

Clinical vignette # 11

A 24 year old female is admitted with SOB and productive cough which was dry at first and is nowproductive of thick yellow sputum.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Pneumonia Chest x-ray shows consolidationAsthma White cell count is overly highCOPD Symptom occurred after a viral

infection

Clinical vignette # 12

59

A 23 year old presents with severe SOB with whitish frothy sputum.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Asthma Peak flow is 30% of her normal.Pneumonia Has a history of admissions for the

same conditionCOPD Not a smoker

Clinical Vignette # 13

Mr. X is admitted at the Acute Medical Ward with:cough that is almost continuous and coughing up blood

have a consistent fever, including low-grade fevers with night sweats

chest pains and unexplained weight loss

If you were thinking of New information Your hypothesis is-2 = greatly

weakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Pulmonary TB Sputum culture showsMycobacterium tuberculosis

Pneumonia Sputum culture showsMycobacterium tuberculosis.

Asthma Family history of Asthma

Clinical Vignette # 14

James presents with cough, wheezing, fever, chills and malaise, and shortness of breath especiallywith exertion. He is a heavy smoker.

60

If you were thinking of New information Your hypothesis is-2 = greatly

weakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Chronic Bronchitis Radiological signs includebronchial wall thickening withincreased bronchovascularmarkings, enlarged vessels andcardiomegaly (abnormalenlargement of the heart)

Asthma Radiological signs includebronchial wall thickening withincreased bronchovascularmarkings, enlarged vessels andcardiomegaly (abnormalenlargement of the heart)

Pneumonia Radiological signs includebronchial wall thickening withincreased bronchovascularmarkings, enlarged vessels andcardiomegaly (abnormalenlargement of the heart)

Clinical Vignette # 15

A 18 months old child is admitted with in the Paediatric ward with productive cough and fever.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Bronchiolitis Chest x-ray shows airspaceopacity, lobar consolidation, andinterstitial opacities.

61

Asthma Chest x-ray shows airspaceopacity, lobar consolidation, andinterstitial opacities.

Pneumonia Chest x-ray shows airspaceopacity, lobar consolidation, andinterstitial opacities.

Clinical Vignette # 16

A 63 year old male fell on his hip. He has a sharp pain on the region and cannot move his leg atall due to pain.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Hip dislocation X-ray shows no hip dislocationHip fracture X-ray shows no fractureHip muscle strain X-ray shows no fracture

Clinical Vignette # 17

A 26 year old lady on her 6th month of pregnancy is having severe low back pain.If you were thinking of New information Your hypothesis is

-2 = greatlyweakened,

-1 = slightly weakened,

0 = no effect onhypothesis,

1 = strengthened,

2 = greatlystrengthened

Sacro-iliac joint sprain X-ray shows no bony abnormality.Symphysis Pubis jointdislocation

X-ray shows no bony abnormality.

Back muscle strain The lady is on her first pregnancy.

62

Appendix 2: Fiji National University Research approval

27th October 2016

Dear Venasio Ramabuke

Thank you for your application for review to the College Health Research & EthicsCommittee.

Title of Research: Clinical Education in Physiotherapy: An analysis of ClinicalReasoning amongst Physiotherapy students in Fiji.

I am pleased to advise you that the CHREC has granted FULL approval for yourabove-mentioned study.

Please note that the following conditions apply to your approval. Failure to abide bythese conditions may result in suspension or discontinuation of approval and/ordisciplinary action.

i. Duration of Approval – approval is granted till the duration of project as outlinedin the research proposal. However, if the study cannot be completed in the timeframe given, researcher has to seek an extension by submitting a progress report.

ii. Variation to Project: Any subsequent variations or modifications you mightwish to make to your project must be notified formally to the Chair, CollegeResearch Committee for further considerations and approval.

iii. Incidence or adverse effects: Researchers must report immediately to the Chairof the College Health Research & Ethics Committee.

iv. Monitoring: Projects are subject to monitoring at any time by the Committee.

v. Final Report: You must submit a final report at the conclusion of the project bycompleting the Final Report form.

Please note that all health related research conducted in Fiji using Fiji Ministry ofhealth data, patients, personnel or facilities will have to be reviewed and approvedby the Fiji National Research Ethics Review Committee. If you need an additional

College Health Research and Ethics Committee

(CHREC)

College of Medicine, Nursing and Health Sciences

Research Unit : Office of the Dean

Hoodless House, Fiji National University

PH: 3311700 EXT: 3018

63

approval from the Fiji MOH, please apply via the Fiji Health Research Portal orusing this link: http://health.gov.fj/fijihrp/index.php?journal=hrp

If you have any further queries on these matters or require information, please do nothesitate to contact the secretariat on telephone: (679) 323 3406 or email: CMNHS-RCO@fnu.ac.fj

Yours sincerely,

........................

Mohseen Khan- CHREC Secretariat/ CMNHS Research Officer

Ufs. and for Prof. Rajanishwar Gyaneshwar

Chair: College Health Research & Ethics Committee

Associate Dean Research, College of Medicine Nursing & Health Sciences

64

Appendix 3: University of the South Pacific Ethics Approval

65

Appendix 4: Informed Consent to Participate

Topic: Clinical Education in Physiotherapy: An analysis of Clinical Reasoningamongst Physiotherapy students in Fiji.

You have been asked to participate in a research study conducted by Mr. VenasioRamabuke a student from the University of the South Pacific. The purpose of thestudy is to analyse clinical reasoning amongst Physiotherapy students in Fiji. Youwere selected as a possible participant in this study because you are a current clinicalPhysiotherapy student. You should read the information below, and ask questionsabout anything you do not understand, before deciding whether or not to participate.

• Participation is voluntary. You have the right not to answer any question, and tostop the test at any time or for any reason. I expect that the interview will take about45 - 60 minutes

• You will not be compensated for participating.

• Unless you give me permission to use your name, title, and / or quote you in anypublications that may result from this research, the information you tell us will beconfidential.

• I would like to record this test so that I can use it for reference while proceedingwith this study. I will not record this interview without your permission. If you dogrant permission for this conversation to be recorded, you have the right to revokerecording permission and/or end the interview at any time.

This project will be completed by within the next 3 months. All test recordings willbe stored in a secure work space until 1 year after that date. The recordings will thenbe deleted.

I understand the procedures described above. My questions have been answered tomy satisfaction, and I agree to participate in this study. I have been given a copy ofthis form.

Name of Participant: ______________________________

Signature of Participant_______________________________ Date ____________

Signature of Researcher _________________________Date _________

Please contact me with any questions or concerns and thank you for your assistanceand co-operation.

66

Appendix 5: List of courses in the Bachelor Physiotherapy program (As at Aug,

2017)

Year I courses

BMS 501 Introduction to Biomedical Sciences

PHT 501 Introduction to Physiotherapy

EPI 501 Introduction to Basic Epidemiology

LNG 501 English for Academic Studies

BMS 502 Musculoskeletal Systems

PHT 507 Physiotherapy Theory and Practice 1 (Musculoskeletal)

HPM 501 Introduction to Health Psychology

Year II courses

BMS 601 Cardiorespiratory Systems

PHT 607 Physiotherapy Theory and Practice 2(Cardiorespiratory)

BMS 602 Neurological Systems plus Vertebral Anatomy

PHT 608 Physiotherapy Theory and Practice 3 (Neurology)

HPM 705 Applied Health Psychology

Year III courses

PHT 713 Cardiorespiratory Physiotherapy

PHT 708 Musculoskeletal Physiotherapy

PHT 709 Neurological Physiotherapy

PHT 710 Evidence Based Physiotherapy Practice 1

PHT 712 Professional Physiotherapy Practice 1

PHT 707 Clinical Education 1-3

PHT 711 Physiotherapy across the lifespan (Paediatrics)

Year IV courses

PHT 715 Advanced Exercise prescriptionPHT 717 Evidence based Practice 2PHT 718 Professional Physiotherapy Practice 2PHT 719 RehabilitationPHT 716 Physiotherapy Across the Adult Life SpanHPM 703 Case Studies and Special Issues in Health PromotionPHT 720 ElectivePHT 714 Clinical Education 4-7

67

Appendix 6: Physiotherapy Clinical Assessment form

CLINICAL EXAMINATIONS ASSESSMENT FORM

Student: ______________________ Date: ______________

Ward/Area of Work:___________________

Assessment scale - points are of equal weighting. Circle the number on the scaleopposite each objective:

0 1 2 3 4 5 6 7 8 9 10

extremely very poor clear just clear very excellent

poor fail pass pass good

OBJECTIVES GRADE

ASSESSMENT:

1. Reviews and summarizes information from patient 0 1 2 3 4 5 6 7 8

9 10

records (charts, x-rays, tests, other relevant documents)

2. Prepares & positions patient/environment correctly, 0 1 2 3 4 5 6 7 8 9

10

efficiently, giving clear & relevant information

3. Uses appropriate exam procedure relevant to the 0 1 2 3 4 5 6 7 8 9 10

diagnosis to demonstrate proficiency in testing skills

4. Adapts handling procedures to patient’s physical state 0 1 2 3 4 5 6 7 8

9 10

5. Examines in a logical & systematic sequence 0 1 2 3 4 5 6 7 8 9 10

6. Completes a comprehensive assessment 0 1 2 3 4 5 6 7 8 9 10

7. Summarises assessment findings 0 1 2 3 4 5 6 7 8 9 10

TREATMENT:

68

1. Justifies selection of appropriate treatment 0 1 2 3 4 5 6 7 8 9 10

techniques

2. Demonstrates a variety of treatment strategies 0 1 2 3 4 5 6 7 8 9 10

and skills

3. Performs procedures safely 0 1 2 3 4 5 6 7 8 9 10

4. Performs procedures effectively and skillfully 0 1 2 3 4 5 6 7 8 9 10

5. Procedures are well sequenced 0 1 2 3 4 5 6 7 8 9 10

6. Assesses patients performance during treatment 0 1 2 3 4 5 6 7 8 9 10

7. Makes appropriate changes where necessary 0 1 2 3 4 5 6 7 8 9 10

8. Outlines prognosis and further management 0 1 2 3 4 5 6 7 8 9 10

9. Provides home program/patient education 0 1 2 3 4 5 6 7 8 9 10

10. Re-evaluates treatment outcomes objectively 0 1 2 3 4 5 6 7 8 9 10

KNOWLEDGE:

1. Demonstrates understanding of the patients’ condition 0 1 2 3 4 5 6 7

8 9 10

2. Demonstrates sound logical clinical reasoning 0 1 2 3 4 5 6 7

8 9 10

3. Defines & prioritizes problems relevant to the condition 0 1 2 3 4 5 6 7

8 9 10

4. Prioritizes problems taking into account the patient’s 0 1 2 3 4 5 6 7

8 9 10

perceptions and functional needs

5. Discusses correct Physiotherapy management 0 1 2 3 4 5 6 7

8 9 10

6. Considers precautions/dangers/contraindications 0 1 2 3 4 5 6 7

8 9 10

where applicable

PROFESSIONALISM:

69

1. Demonstrates appropriate interpersonal skills 0 1 2 3 4 5 6 7

8 9 10

e.g. listening, respect for patients privacy

2. Records accurately 0 1 2 3 4 5 6 7

8 9 10

3. Organizes time appropriately 0 1 2 3 4 5 6 7

8 9 10

4. Ensures safety of self and patient 0 1 2 3 4 5 6 7

8 9 10

5. Is able to critically evaluate own performance 0 1 2 3 4 5 6 7

8 9 10

Total Mark: ________________ Grade:

________________

Examiner’s comments & signature:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

70

Appendix 7: Expert Clinicians SCT Raw Data

Expert Number and ScoresVignettes

1 2 3 4 5 6 7 8 9 10 11 12 13

C11 0 1 -2 2 0 -1 1 0 2 -1 -1 0 1

Score 1 0.75

0.25

0.5 1 0.75

0.75

1 0.5 0.75

0.75

1 0.75

2 2 2 2 2 2 2 2 1 1 1 1 2 2Score 1 1 1 1 1 1 1 0.4 0.4 0.4 0.4 1 1

3 -2 -2 1 -2 -2 0 1 -2 0 0 0 -2 -2Score 1 1 0.2

91 1 0.5

70.29

1 0.57

0.57

0.57

1 1

C21 1 1 1 0 2 2 1 1 -1 0 0 0 0

Score 1 1 1 1 0.4 0.4 1 1 1 1 1 12 0 1 0 2 0 1 0 0 -2 -1 -1 0 1

Score 1 0.51

1 0.17

1 0.51

1 1 0.17

0.33

0.33

1 0.51

3 2 1 1 2 1 2 1 1 0 1 1 1 2Score 0 1 1 0 1 0 1 1 0.1

31 1 1 0

C31 0 1 1 0 1 2 0 0 -1 -1 -1 0 0

Score 1 0.5 0.5 1 0.5 0.17

1 1 0.5 0.5 0.5 1 1

2 -1 0 0 2 -1 -1 -1 -1 -2 0 0 0 -1Score 1 0.8

30.83

0 1 1 1 1 0.17

0.83

0.83

0.83

1

3 2 2 1 2 2 2 2 2 0 2 2 2 2Score 1 1 0.0

91 1 1 1 1 0.0

91 1 1 1

C41 -2 0 -1 -2 -1 2 -1 -2 -1 1 1 -2 -1

Score 0.8 0.2 1 0.8 1 0.2 1 0.8 1 0.4 0.4 0.8 12 1 2 1 2 1 -1 -1 2 -2 2 2 2 1

Score 0.6 1 0.6 1 0.6 0.33

0.33

1 0.17

1 1 1 0.6

3 -2 0 2 -2 -1 -2 -1 -1 0 0 0 -2 -2Score 1 0.8 0.2 1 0.6 1 0.6 0.6 0.8 0.8 0.8 1 1

C51 2 -1 -1 1 0 2 -1 -1 0 2 2 0 -1

Score 0.8 1 1 0.2 0.6 0.8 1 1 0.6 0.8 0.8 0.6 12 -1 -1 -1 -2 -1 -2 0 -1 -1 -2 -2 0 -1

71

Score 1 1 1 0.57

1 0.57

0.29

1 1 0.57

0.57

0.29

1

3 2 2 1 2 1 2 2 2 1 -1 -1 2 2Score 1 1 0.3

81 0.3

81 1 1 0.3

80.25

0.25

1 1

C61 2 2 2 2 2 2 2 2 2 2 2 2 2

Score 1 1 1 1 1 1 1 1 1 1 1 1 12 -2 2 -1 -2 -1 -1 -1 -2 1 1 1 -2 -2

Score 1 0.4 0.8 1 0.8 0.8 0.8 1 0.6 0.6 0.6 1 13 2 2 1 1 2 2 0 -1 0 -1 -1 0 1

Score 1 1 0.5 0.5 1 1 1 0.6 1 0.6 0.6 1 0.5C71 2 1 -1 0 0 1 1 1 1 1 1 0 2

Score 0.29

1 0.14

0.43

0.43

1 1 1 1 1 1 0.43

0.29

2 2 2 2 2 1 1 2 2 2 2 2 2 -2Score 1 1 1 1 0.2 0.2 1 1 1 1 1 1 0.1

3 -2 -2 -1 -2 -2 0 1 0 -1 -1 -1 -2 -2Score 1 1 1 1 0.3

30.17

0.33

0.67

0.67

0.67

1 1

C81 0 1 -1 0 0 1 0 2 1 2 2 1 -2

Score 1 1 0.25

1 1 1 1 0.25

1 0.25

0.25

1 0.25

2 -2 -1 1 -2 -2 -2 -1 -2 0 1 1 -1 -2Score 1 0.5 0.5 1 1 1 0.5 1 0.1

70.5 0.5 0.5 1

3 -2 -2 -1 0 -1 -2 0 1 -1 -1 -1 -2 0Score 0.8 0.8 1 0.6 1 0.8 0.6 0.2 1 1 1 0.8 0.6

C91 2 2 1 1 1 1 1 2 1 1 1 1 1

Score 0.3 0.3 1 1 1 1 1 0.3 1 1 1 1 12 1 2 2 -1 1 1 2 2 0 2 2 1 0

Score 0.67

1 1 0.17

0.67

0.67

1 1 0.33

1 1 0.67

0.33

3 -1 -1 -1 -2 0 -2 -1 -1 -1 0 0 -1 0Score 1 1 1 0.2

90.57

0.29

1 1 1 0.57

0.57

1 0.57

C101 1 2 1 2 0 1 1 1 2 1 1 0 2

Score 1 0.43

1 0.43

0.43

1 1 1 0.43

1 1 0.43

0.43

2 -2 -2 0 -2 0 0 1 1 1 2 2 0 0Score 0.6 0.6 1 0.6 1 1 0.6 0.6 0.6 0.4 0.4 1 1

72

3 -2 -2 -1 -2 -2 0 -1 -1 0 0 0 2 1Score 1 1 0.7

51 1 1 0.7

50.75

1 1 1 0.25

0.25

C111 2 2 1 2 2 2 2 2 1 2 2 2 2

Score 1 1 0.18

1 1 1 1 1 0.18

1 1 1 1

2 1 1 1 -2 1 1 1 1 2 1 1 0 1Score 1 1 1 0.1 1 1 1 1 0.1 1 1 0.1 1

3 -1 1 -1 -1 0 1 -1 2 0 0 0 1 0Score 0.8 0.6 0.8 0.8 1 0.6 0.8 0.2 1 1 1 0.6 1C12

1 2 2 2 2 2 2 1 1 1 2 2 2 2Score 1 1 1 1 1 1 0.3 0.3 0.3 1 1 1 1

2 1 1 1 0 1 2 1 2 0 1 1 0 -2Score 1 1 1 0.4

31 0.2

91 0.2

90.43

1 1 0.43

0.14

3 -1 -1 -1 -1 0 -1 -1 1 0 0 0 -1 1Score 1 1 1 1 0.5

71 1 0.2

90.57

0.57

0.57

1 0.29

C131 2 2 2 2 2 2 1 2 2 2 2 2 1

Score 1 1 1 1 1 1 0.18

1 1 1 1 1 0.18

2 -2 -2 -1 -2 -2 2 1 -2 1 1 1 -2 -2Score 1 1 0.1

41 1 0.1

40.57

1 0.57

0.57

0.57

1 1

3 1 -2 0 0 1 1 2 1 0 0 0 0 -2Score 0.6

70.33

1 1 0.67

0.67

0.17

0.67

1 1 1 1 0.33

C141 2 2 1 2 1 2 1 1 1 2 2 2 1

Score 1 1 0.86

1 0.86

1 0.86

0.86

0.86

1 1 1

2 -1 1 -1 -2 -1 1 1 -1 -1 1 1 0 -2Score 1 1 1 0.4 1 1 1 1 1 1 1 0.2 0.4

3 -2 1 0 -2 -1 1 0 0 -2 -1 -1 -2 -2Score 1 0.4 0.6 1 0.6 0.4 0.6 0.6 1 0.6 0.6 1 1C15

1 -1 2 1 -2 1 2 -1 -2 1 -1 -1 0 1Score 1 0.5 1 0.5 1 0.5 1 0.5 1 1 1 0.2

51

2 -1 -1 -1 -2 -1 1 1 -2 -1 1 1 -2 1Score 1 1 1 0.6 1 1 1 0.6 1 1 1 0.6 1

3 2 2 2 2 2 2 2 2 -2 2 2 2 2

73

Score 1 1 1 1 1 1 1 1 0.08

1 1 1 1

C161 -2 -1 -1 -2 -2 -2 -1 -2 -2 -1 -1 -2 -2

Score 1 0.63

0.63

1 1 1 0.63

1 1 0.63

0.63

1 1

2 -2 -1 -1 -1 -2 -2 -1 -2 -1 -2 -2 -2 -2Score 1 0.6

30.63

0.63

1 1 0.63

1 0.63

1 1 1 1

3 0 1 1 2 0 2 0 0 0 0 0 0 1Score 1 0.3

80.38

0.25

1 0.25

1 1 1 1 1 1 0.38

C171 0 2 1 2 0 1 0 0 0 -2 -2 0 1

Score 1 0.33

0.5 0.33

1 0.5 1 1 1 0.17

0.17

1 0.5

2 -2 2 -1 -2 0 1 -1 -2 1 0 0 -2 -1Score 1 0.2

50.75

1 0.75

0.75

0.75

1 0.75

0.75

0.75

1 0.75

3 1 2 0 1 2 1 1 1 -1 -1 -1 1 1Score

74

Appendix 8: BPT Year 4 students SCT Raw Data

BPT04 Student Number and Scores1 Score 2 Score 3 Score 4 Score 5 Score 6 Scor

eC11 0 1 1 0.75 0 1 0 1 0 1 0 12 -1 0 2 1 2 1 2 1 2 1 1 0.43 -2 1 -1 0 -2 1 -2 1 -2 1 -2 1C21 2 0.4 2 0.4 2 0.4 1 1 1 1 1 12 0 1 1 0.51 -2 0.17 0 1 0 1 0 13 -1 0 1 1 2 0.5 2 0.5 1 1 1 1C31 2 0.17 2 0.17 2 0.17 0 1 1 0.5 0 12 -2 0.17 -1 1 -2 0.17 -1 1 0 0.83 -1 13 -2 0 2 1 2 1 2 1 2 1 1 0.09C41 2 0.2 -2 0.8 -2 0.8 -2 0.8 0 0.2 1 0.42 1 0.6 2 1 0 0 1 0.6 1 0.6 -1 0.333 2 0.2 -2 1 -2 1 -2 1 -2 1 -2 1C51 2 0.8 -2 0 -2 0 -2 0 0 0.6 -2 02 -2 0.57 -2 0.57 -2 0.57 -1 1 0 0.29 -2 0.573 -2 0 1 0.38 2 1 2 1 1 0.38 1 0.38C61 0 0 2 1 2 1 2 1 1 0 2 12 -1 0.8 1 0.6 2 0.4 -2 1 -1 0.8 -2 13 -2 0 2 1 0 1 1 0.5 0 1 1 0.5C71 2 0.29 1 1 2 0.29 0 0.43 -1 0.14 -1 0.142 0 0 2 1 2 1 1 0.2 2 1 1 0.23 1 0.17 0 0.33 2 0 0 0.33 -2 1 0 0.33C81 0 1 0 1 2 0.75 1 1 -2 0.25 1 12 -1 0.5 0 0.17 2 0 -2 1 -2 1 -2 13 2 0 -2 0.8 -2 0.8 -2 0.8 0 0.6 -1 1C91 1 1 1 1 2 0.3 2 0.3 1 1 2 0.32 2 1 2 1 0 0.33 1 0.67 -1 0.17 1 0.673 -2 0.29 -2 0.29 -2 0.29 -2 0.29 -2 0.29 -2 0.29C101 0 0.43 2 0.43 2 0.43 1 1 1 1 1 1

75

2 1 0.6 2 0.4 -2 0.6 0 1 0 1 0 13 -2 1 -1 0.75 0 1 0 1 0 1 0 1C111 0 0 2 1 2 1 2 1 2 1 2 12 1 1 2 0.1 0 0.1 0 0.1 0 0.1 0 0.13 2 0.2 2 0.2 2 0.2 0 1 1 0.6 0 1C121 0 0 0 0 2 1 1 0.3 1 0.3 0 02 -2 0.14 1 1 0 0.43 2 0.29 0 0.43 1 13 1 0.29 -2 0 0 0.57 -1 1 -1 1 -1 1C131 2 1 2 1 2 1 2 1 2 1 2 12 2 0.14 1 0.57 2 0.14 0 0 -2 1 0 03 2 0.17 1 0.67 0 1 0 1 1 0.67 0 1C141 0 0 2 1 2 1 2 1 2 1 2 12 0 0.2 1 1 -1 1 -2 0.4 -2 0.4 -2 0.43 0 0.6 1 0.4 -2 1 0 0.6 -2 1 0 0.6C151 -2 0.5 -1 1 2 0.5 -1 1 -2 0.5 -2 0.52 -2 0.6 -1 1 2 0 0 0 -2 0.6 0 03 0 0 2 1 0 0 2 1 2 1 1 0C161 -2 1 -2 1 0 0 -2 1 -2 1 -2 12 -2 1 -2 1 2 0 -2 1 -2 1 -2 13 2 0.25 0 1 2 0.25 0 1 0 1 0 1C171 0 1 1 0.5 2 0.33 0 1 0 1 -1 02 2 0.75 0 0.75 0 0.75 -2 1 -2 1 0 0.753 2 0.29 1 1 2 0.29 2 0.29 2 0.29 1 1

BPT04 Student Number and Scores7 Score 8 Score 9 Score 10 Score 11 Score

C11 0 1 2 0.5 -1 0.75 0 1 1 0.752 2 1 -2 0 2 1 2 1 2 13 -

21 2 0 -1 0 0 0.57 -2 1

C21 2 0.4 -1 0.2 2 0.4 2 0.4 1 12 1 0.51 1 0.51 -2 0.17 0 1 2 0.173 1 1 2 0.5 1 1 2 0.5 1 1

76

C31 1 0.5 -1 0.5 1 0.5 1 0.5 1 0.52 -

11 -1 1 -2 0.17 2 0 -2 0.17

3 2 1 2 1 2 1 -2 0 2 1C41 -

11 -1 1 -1 1 2 0.2 -2 0.8

2 1 0.6 -1 0.33 0 0 0 0 1 0.63 -

21 -2 1 -1 1 0 0 -2 1

C51 -

20 -1 1 -2 0 -1 1 0 0.6

2 -1

1 -1 1 -1 1 0 0.29 -1 1

3 2 1 2 1 2 1 2 1 1 0.38C61 2 1 2 1 2 1 2 1 2 12 -

10.8 -2 1 0 0 0 0 -2 1

3 1 0.5 2 1 1 0.5 0 1 2 1C71 1 1 2 0.29 2 0.29 2 0.29 2 0.292 1 0.2 -2 0.1 1 0.2 1 0.2 2 13 0 0.33 0 0.33 0 0.33 0 0.33 -1 0.67C81 1 1 2 0.75 1 1 2 0.75 1 12 -

10.5 -2 1 -2 1 0 0.17 -2 1

3 0 0.6 -2 0.8 0 0.6 0 0.6 -2 0.8C91 2 0.3 2 0.3 2 0.3 2 0.3 1 12 -

10.17 -1 0.17 1 0.67 1 0.67 1 0.67

3 0 0.57 0 0.57 -2 0.29 0 0.57 -2 0.29C101 2 0.43 2 0.43 2 0.43 2 0.43 2 0.432 1 0.6 0 1 0 1 -2 0.6 -2 0.63 0 1 -2 1 0 1 0 1 -2 1C111 2 1 2 1 1 1 1 1 2 12 1 1 -1 0 -2 0.1 2 0.1 -2 0.13 2 0.2 -1 0.8 2 0.2 0 1 -2 0C12

77

1 1 0.3 2 1 2 1 2 1 2 12 1 1 0 0.43 1 0 2 1 0 0.433 -

11 -1 1 0 0.57 0 0.57 -1 1

C131 2 1 2 1 2 1 2 1 2 12 0 0 -1 0.14 -2 1 1 0.57 -2 13 0 1 0 1 1 0.67 0 1 0 1C141 2 1 2 1 2 1 2 1 2 12 1 1 -1 1 -2 0.4 2 0 1 13 -

21 -1 0.6 -2 1 2 0 -2 1

C151 1 1 -2 0.5 -1 1 0 0.25 -1 12 -

11 -2 0.6 -1 1 0 0 -2 0.6

3 2 1 2 1 2 1 2 1 2 1C161 0 0 -2 1 -1 0.63 2 0 -2 12 0 0 -2 1 -1 0.63 2 0 -2 13 1 0.38 -2 0 2 0.25 0 1 1 0.38C171 -

10 0 1 -2 0.17 0 1 1 0.5

2 -2

1 -1 0.75 -1 0.75 2 0.75 -2 1

3 1 1 2 0.29 2 0.29 1 1 2 0.29

78

Appendix 9: BPT Year 3 SCT Raw Data

BPT03 Student Number and Scores1 Score 2 Score 3 Score 4 Score 5 Score

C11 0 1 -1 0.75 -1 0.75 0 1 1 0.752 2 1 2 1 2 1 1 0.4 2 13 -2 1 -2 1 -1 0 -1 0 2 0C21 1 1 2 0.4 2 0.4 1 1 0 12 0 1 0 1 -2 0.17 0 1 0 13 1 1 -2 0 0 0.13 1 1 2 0.5C31 1 0.5 1 0.5 2 0.17 1 0.5 2 0.172 0 0.83 -1 1 -2 0 0 0.83 0 0.833 2 1 2 1 1 0.09 1 0.09 0 0.09C41 -2 0.8 0 0.2 -1 1 1 0.4 2 0.22 1 0.6 1 0.6 2 1 1 0.6 -2 0.173 -2 1 -2 1 -1 0.6 1 0 -2 1C51 -1 1 -1 1 -2 0 1 0.2 2 0.82 2 0 0 0.29 -2 0.57 2 0 -2 0.573 2 1 -1 0.25 2 1 1 -2 0C61 1 0 1 0 2 1 2 1 2 12 2 0.4 2 0.4 -2 1 1 0.6 -1 0.83 1 0.38 1 0.38 2 1 1 0.38 -2 0C71 1 1 -1 0.14 -2 0 2 0.29 0 0.432 1 0.2 1 0.2 2 1 1 0.2 2 13 -2 1 0 0.33 -2 1 1 0.17 -2 1C81 -2 0.25 -1 0.25 2 0.75 1 1 -2 0.252 -2 1 0 0.17 -2 1 2 0 -2 13 -2 0.8 0 0.6 -2 0.8 1 0.2 -2 0.8C91 2 0.3 2 0.3 2 0.3 2 0.3 2 0.32 1 0.67 1 0.67 2 1 1 0.67 2 13 -2 0.29 -2 0.29 -1 1 1 0 -2 0.29C101 1 1 2 0.3 1 1 1 1 2 0.32 -2 0.6 2 0.4 0 1 2 0.4 -2 0.6

79

3 -2 1 2 0.25 -1 0.75 1 0.25 -2 1C111 1 0.18 1 0.18 2 1 2 1 2 12 1 1 -2 0.1 2 0.1 1 1 -2 0.13 -2 0 2 0.2 -1 0.8 2 0.2 -2 0C121 1 0.3 2 1 2 1 1 0.3 2 12 1 1 0 0.43 -1 0 0 0.43 2 0.293 -1 1 0 0.57 -2 0 1 0.67 -2 0C131 2 1 2 1 2 1 1 0.18 1 0.182 -1 0.14 -1 0.14 1 0.57 2 0.14 0 03 1 0.67 1 0.67 1 0.67 0 1 0 1C141 -1 0 2 1 1 0.86 2 1 -2 02 1 1 -1 1 2 0 1 1 2 03 1 0.4 -1 0.6 0 0.6 1 0.4 2 0C151 -1 1 1 1 -2 0.5 1 1 0 0.252 -2 0.6 -1 1 -2 0.6 1 1 1 13 2 1 2 1 2 1 1 0 2 1C161 -1 0.63 -2 1 -2 1 0 0 -2 12 -1 0.63 -2 1 -2 1 1 0 0 03 0 1 -2 0 2 0.25 1 0.38 -2 0C171 -1 0 -1 0 -2 0.17 0 1 0 12 -1 0.75 -1 0.75 -2 1 1 0.5 0 0.753 1 1 2 0.29 2 0.29 1 1 2 0.29

BPT03 Student Number and Scores6 Score

s7 Score

s8 Score

s9 Score

s10 Score

sC11 1 0.75 -1 0.75 2 0.5 -1 0.75 0 12 1 0.4 2 1 2 1 2 1 2 13 -1 0 -2 1 -2 1 0 0.57 -2 1C21 1 1 2 0.4 0 1 1 1 2 0.42 0 1 -1 0.33 1 0.51 0 1 -2 0.173 1 1 2 0.5 1 1 2 0.5 2 0.5C3

80

1 0 1 1 0.5 1 0.5 2 0.17 2 0.172 -1 1 -1 1 -1 1 1 0 0 0.833 2 1 2 1 1 0.09 2 1 2 1C41 -1 1 0 0.2 -2 0.8 -1 1 -1 12 2 1 1 0.6 1 0.6 -2 0.17 1 0.63 1 0 2 0.2 -2 1 -1 0.6 -2 1C51 -1 1 -1 1 -2 0 1 0.2 -2 02 -2 0.57 2 0 -1 1 -1 1 2 03 1 0.38 2 1 2 1 2 1 2 1C61 2 1 1 0 2 1 2 1 2 12 1 0.6 1 0.6 2 0.4 1 0.6 2 0.43 1 0.38 2 1 2 1 2 1 2 1C71 1 1 1 1 0 0.43 -1 0.14 2 0.292 -1 0 1 0.2 2 1 2 1 2 13 -1 0.67 2 0 -2 1 1 0.17 1 0.17C81 1 1 -2 0.25 0 1 0 1 0 12 -2 1 2 0 -2 1 1 0.5 -2 13 -1 1 1 0.2 -2 0.8 2 0 -2 0.8C91 2 0.3 1 1 2 0.3 1 1 2 0.32 -1 0.5 1 0.67 1 0.67 2 1 2 13 -2 0.29 -1 1 -2 0.29 1 0 -2 0.29C101 2 0.3 1 1 1 1 1 1 2 0.32 1 0.67 -1 0 0 1 0 1 2 0.43 0 1 2 -2 1 0 1 0 1C111 1 0.18 2 1 2 1 2 1 2 12 1 1 -2 0.1 2 0.1 2 0.1 2 0.13 2 0.2 1 0.6 -2 0 2 0.2 1 0.6C121 1 0.3 0 2 1 1 0.3 2 12 1 1 1 1 2 0.29 2 0.29 2 0.293 0 0.57 -2 0 -1 1 2 0 2 0C1

81

31 1 0.18 1 0.18 2 1 2 1 2 12 2 0.14 2 0.14 -1 0.14 2 0.14 2 0.143 1 0.67 1 0.67 2 0.17 2 0.17 2 0.17C141 2 1 1 0.86 1 0.86 2 1 2 12 1 1 1 1 1 1 1 1 2 03 1 0.4 2 0 1 0.4 2 0 2 0C151 1 1 -1 1 1 1 1 1 1 12 -1 1 -1 1 -1 1 1 2 03 1 0 2 1 2 1 2 1 2 1C161 -1 0.63 -2 1 -2 1 -1 0.63 -2 12 -2 1 -1 0.63 -2 1 1 0 -2 13 0 1 -1 0 2 0.25 0 1 -1 0C171 1 0.5 -1 0 2 0.33 2 0.33 -1 02 1 0.5 1 0.5 -2 1 1 0.5 -2 13 2 0.29 2 0.29 1 1 2 0.29 2 0.29

BPT03 Student Number and Scores11 Score

s12 Score

s13 Score

s14 Score

s15 Score

sC11 0 1 0 1 0 1 0 1 -1 0.752 2 1 2 1 2 1 2 1 2 13 -2 1 -2 1 1 0.29 -2 1 -2 1C21 2 0.4 2 0.4 2 0.4 0 1 0 12 0 1 -1 0.33 0 1 0 1 -2 0.173 1 1 1 1 2 0.5 1 1 1 1C31 0 1 2 0.17 2 0.17 1 0.5 1 0.52 0 0.83 -1 1 2 0 -2 0 -2 03 2 1 1 0.09 1 0.09 2 1 1 0.09C41 -2 0.8 2 0.2 2 0.2 -2 0.8 -1 12 -1 0.33 0 0 0 0 -2 0.17 1 0.6

82

3 -2 1 -2 1 2 0.2 -2 1 -1 0.6C51 -1 1 1 0.2 -1 1 -1 1 -1 12 -2 0.57 -1 1 0 0.29 2 0 -2 0.573 -2 0 2 1 0 0 2 1 1 0.38C61 2 1 2 1 2 1 2 1 2 12 2 0.4 0 0 1 0.6 0 0 2 0.43 2 1 1 0.5 0 0 -2 0 0 0C71 2 0.29 2 0.29 2 0.29 -2 0 1 12 2 1 2 1 0 0 2 1 2 13 -2 1 0 0.33 1 0.17 1 0.2 1 0.2C81 -2 0.25 2 0.75 2 0.75 -2 0.25 0 12 -2 1 -1 0.5 2 0 0 0.17 -2 13 -2 0.8 -2 0.8 2 0 0 0.6 0 0.6C91 2 0.3 0 0 2 0.3 2 0.3 2 0.32 -2 0 2 1 2 1 0 0.33 1 0.673 -2 0.29 -2 0.29 0 0.57 -2 0.29 -2 0.29C101 2 0.3 2 0.3 2 0.3 -2 0 0 0.432 -1 0 1 0.67 2 0.4 2 0.4 0 13 -1 0.75 0 1 1 0.25 0 1 -2 1C111 2 1 2 1 1 0.18 2 1 2 12 -1 0 -1 0 0 0.1 -1 0 2 0.13 -2 0 0 1 2 0.2 0 1 2 0.2C121 2 1 2 1 1 0.3 2 1 -1 02 1 1 2 0.29 2 0.29 2 0.29 2 0.293 0 0.57 -1 1 1 0.67 -2 0 -2 0C131 1 0.18 2 1 1 0.18 2 1 2 12 2 0.14 0 0 0 0 1 0.57 1 0.573 2 0.17 0 1 2 0.17 -2 0.33 2 0.17C141 1 0.86 0 0 2 1 1 0.86 -2 0

83

2 1 1 -1 1 1 1 -1 1 -2 0.143 -2 1 2 0 1 0.4 2 0 -2 1C151 1 1 2 0.5 0 0.25 2 0.5 2 0.52 -1 1 0 0 1 1 0 0 -1 13 2 1 1 0 2 1 1 0 2 1C161 -2 1 -2 1 1 0 -2 1 -2 12 -2 1 -2 1 1 0 -2 1 -2 13 0 1 0 1 0 1 -2 0 0 1C171 0 1 0 1 1 0.5 -1 0 0 12 -2 1 1 0.5 0 0.75 0 0.75 -2 13 2 0.29 2 0.29 2 0.29 -1 0.43 2 0.29

BPT03 Student Number and Scores16 Score

s17 Score

s18 Score

s19 Score

s20 Score

sC11 0 1 -2 0.25 -1 0.75 0 1 2 0.52 2 1 2 1 2 1 2 1 2 13 -2 1 -2 1 0 0.57 1 -2C21 2 0.4 1 1 -2 0 -2 0 2 0.42 0 1 2 0.17 2 0.17 2 0.17 2 0.173 -1 0 -1 0 0 0.13 -2 0 2 0.5C31 -1 0.5 1 0.5 2 0.2 -2 0 0 12 1 0 1 0 -2 0.17 2 0 -2 0.173 2 1 2 1 2 1 -1 2 1C41 -2 0.8 -2 0.8 2 0.2 2 0.2 -1 12 -2 0.17 0 0 -2 0.17 0 0 -2 0.173 -2 0.2 -2 0.2 -2 0.2 2 -2 0.2C51 -2 0 -2 0 2 0.8 0 0.6 -2 02 -1 1 -2 0.57 1 0 2 0 -2 0.573 0 0 2 1 0 0 2 1 -2 0C61 2 1 2 1 2 1 2 1 2 1

84

2 2 0.4 -1 0.8 -1 0.8 -1 0.8 1 0.63 1 0.5 2 1 -2 0 -1 0.6 1 0.5C71 0 0.43 0 0.43 0 0.43 0 0.43 0 0.432 2 1 2 1 2 1 2 1 2 13 -2 1 -2 1 -1 0.67 1 0.2 -2 1C81 2 0.75 1 1 -2 0.25 2 0.75 2 0.752 0 0.17 -2 1 -1 0.5 -2 1 -2 13 0 0.6 -2 0.8 -2 0.8 0 0.6 0 0.6C91 2 0.3 -2 0 1 1 1 1 -1 02 0 0.33 2 1 0 0.33 2 1 2 13 0 0.57 -2 0.29 -2 0.29 0 0.6 -2 0.29C101 0 0.43 2 0.3 -2 0 -2 0 2 0.32 0 1 0 1 0 1 1 0.7 -23 0 1 -2 1 -2 1 0 1 -2 1C111 2 1 2 1 2 1 -1 0 2 12 1 1 -2 0.1 2 0.1 1 1 0 0.13 1 0.6 -2 0 1 0.6 -1 0.8 -2 0C121 1 0.3 2 1 2 1 1 0.3 2 12 2 0.29 1 1 2 0.29 1 1 -23 -2 0 -1 1 2 0 2 0 -1 1C131 2 1 2 1 2 1 1 0.2 2 12 2 0.14 -2 1 -2 1 2 0.1 -13 2 0.17 0 1 2 0.2 2 0.2 2 0.2C141 1 0.86 2 1 0 0 2 1 2 12 2 0 -2 0.14 2 0 1 1 1 13 1 0.4 -1 0.6 -1 0.6 1 0.4 -2 1C151 2 0.5 1 1 1 1 1 1 -2 0.52 2 0 1 1 1 1 2 0 -13 2 1 2 1 2 1 -1 0 2 1

85

C161 0 0 -2 1 2 0 0 0 -2 12 0 0 -2 1 -1 0.6 1 0 -2 13 0 1 2 0.25 2 0.25 0 1 2 0.25C171 0 1 -2 0.17 2 0.3 1 0.5 2 0.32 2 0.25 -2 1 2 0.25 2 0.25 -2 13 -2 0 2 0.29 2 0.3 -1 0.43 1 1

BPT03 Student Number and Scores21 Score 22 Scor

e23 Score 24 Score 25 Score

C11 2 0.5 0 1 -1 0.75 2 0.5 1 0.752 2 1 1 0.4 2 1 1 0.4 -1 03 2 -2 -2 0 -2C21 2 0.4 0 1 0 1 1 1 1 12 2 0.17 0 1 0 1 0 1 2 0.173 2 0.5 1 1 2 0.5 2 0.5 1 1C31 2 0.2 1 0.5 2 0.2 1 0.5 -2 02 -1 1 0 0.83 0 0.83 0 0.83 -2 0.173 0 2 1 2 1 2 1 1 0.1C41 -2 0.8 0 0.2 0 0.2 -2 0.8 2 0.22 0 0 2 1 -2 0.17 -2 0.17 -2 0.173 -2 0.2 -2 0.2 0 0.8 -2 1 -2 1C51 -2 0 -2 0 -1 1 1 0.2 2 0.82 -2 0.57 -2 0.57 -1 1 -1 1 0 0.33 0 0 1 0.38 2 1 -1 0.25 1 0.38C61 2 1 2 1 2 1 1 0 2 12 2 0.4 -1 0.8 2 0.4 2 0.4 -1 0.83 -2 0 1 0.5 2 1 1 0.5 1 0.5C71 -1 0.14 0 0.43 -1 0.14 2 0.3 1 12 2 1 1 0.2 1 0.2 1 0.2 2 13 2 0 -2 1 -2 1 -1 0.67 0 0.3C8

86

1 -2 0.25 0 1 1 1 0 1 2 0.752 -2 1 -2 1 -1 0.5 -2 1 0 0.23 -2 0.8 -2 0.8 -1 1 -1 1 0 0.6C91 2 0.3 1 1 2 0.3 1 1 1 12 2 1 1 0.7 1 0.7 2 1 2 13 -2 0.29 -2 0.29 -2 0.29 -2 0.29 0 0.6C101 2 0.3 1 1 0 0.43 1 1 1 12 -2 0 1 -1 0 -1 0 -1 03 -1 -2 1 -2 1 0 1 0 1C111 2 1 2 1 2 1 2 1 2 12 2 0.1 0 0.1 1 1 1 1 1 13 -2 0 -1 0.8 -1 0.8 -2 0 -2 0C121 1 0.3 2 1 1 0 1 0 1 02 2 0.29 2 0.29 2 0.29 1 1 2 0.293 -2 0 0 0.6 -1 1 -2 0 -2 0C131 2 1 1 0.2 2 1 2 1 2 12 -2 1 -1 0.14 1 0.57 2 0.1 -2 13 2 0.2 2 0.2 1 1 -1 0 0 1C141 2 1 1 0.9 2 1 1 0.9 1 0.92 0 0.2 -2 1 1 1 1 0 0.23 0 0.6 -2 1 -2 1 1 0.4 0 0.6C151 1 1 -2 0.5 1 1 1 1 0 0.32 1 1 -2 0.6 -1 1 -1 1 0 03 2 1 2 1 1 0 1 0 2 1C161 -1 1 -2 1 -2 1 -2 1 -1 12 -1 0.6 -2 1 -2 1 -2 1 -2 13 0 1 1 0.38 0 1 -1 0 2 0.25C171 0 1 1 0.5 0 1 -1 0 -1 0

87

2 0 -2 1 -2 1 -1 0.8 1 0.53 2 0.3 2 0.3 2 0.3 1 1 2 0.3

BPT03 Student Number and Scores26

Scores

27 Scores 28 Scores

29 Scores

30 Scores

C11 -2 0.25 -2 0.25 2 0.5 0 1 0 12 2 1 2 1 2 1 2 1 1 0.43 -2 -2 -2 -2 -2C21 0 1 1 1 0 1 2 0.4 0 12 -2 0.17 0 1 -1 0.33 -1 0.33 0 13 1 1 1 1 -2 0 1 1 2 0.5C31 0 1 1 0.5 2 0.2 1 0.5 2 0.22 -2 0.17 1 0 -2 0.17 -1 1 1 03 2 1 1 0.1 2 1 2 1 2 1C41 -2 0.8 -2 0.8 -1 1 -1 1 -1 12 0 0 -1 0.3 -2 0.17 -1 0.3 2 13 -2 1 -2 0.2 -2 1 -2 1 -2 1C51 1 0.2 -1 1 -2 0 -2 0 -1 12 -1 1 -2 0.57 -2 0.57 -2 0.57 -1 13 2 1 2 1 2 1 -2 0 2 1C61 2 1 1 0 2 1 2 1 2 12 2 0.4 0 0 2 0.4 -1 0.8 1 0.63 1 0.5 2 1 2 1 -2 0 2 1C71 0 0.43 0 0.43 2 0.3 1 1 2 0.32 2 1 1 0.2 2 1 2 1 1 0.23 2 0 -2 1 -2 1 -2 1 1 0.2C81 1 1 1 1 -1 1 1 2 0.752 -2 1 -2 1 -2 1 -2 1 0 0.23 0 0.6 -2 0.8 -2 0.8 -2 0.8 -1 1C91 1 1 1 1 2 0.3 2 0.3 2 0.32 2 1 1 0.7 -1 0.5 1 0.7 1 0.73 -2 0.29 -2 0.29 -2 0.29 -2 0.29 0 0.6

88

C101 2 0.3 1 1 2 0.3 1 1 2 0.32 0 1 1 0.7 -1 0 -1 0 1 0.73 -2 1 -2 1 -2 1 -2 1 0 1C111 2 1 2 1 2 1 2 1 1 02 2 0.1 2 0.1 -2 0.1 1 1 1 13 2 0.2 2 0.2 -2 -2 0 2 0.2C121 1 0 1 0 1 0 2 1 2 12 2 0.29 2 0.29 1 1 2 0.29 2 0.293 0 0.6 0 0.6 -1 1 -2 0 1 0.7C131 2 1 2 1 2 1 2 1 2 12 2 0.1 1 0.57 -2 1 -1 0.14 1 0.573 2 0.2 2 0.2 0 1 1 1 0 1C141 1 0.9 2 1 1 0.9 2 1 1 0.92 2 0 1 1 -1 1 1 1 1 13 2 0 2 0 1 0.4 0 0.6 2 0C151 1 1 1 1 -1 1 1 1 0 0.32 2 0 1 1 -2 0.6 -2 0.6 0 03 2 1 2 1 2 1 2 1 2 1C161 -2 1 -2 1 -2 1 -2 1 -1 12 1 -2 1 -2 1 -2 1 -2 13 -2 0 -1 0 1 0.38 0 1 0 1C171 -2 0.17 -2 0.17 1 0.5 0 1 -1 02 -2 1 -2 1 -2 1 -2 1 -1 0.83 1 1 1 1 2 0.3 2 0.3 2 0.3