Exploration of Students’ Clinical Reasoning … of Students...Reasoning Development in Professional Physical Therapy ... ical reasoning is the critical thought process ... in the

22 Journal of Physical Therapy Education Vol 29, No 3, 2015

———————————————————- REsEARch REPORT ———————————————-———-

Exploration of Students’ Clinical Reasoning Development in Professional

Physical Therapy EducationJennifer Furze, PT, DPT, PCS, Lisa Black, PT, DPT, Julie Hoffman, PT, DPT, CCS, JB Barr, PT, DPT, OCS,

Teresa M. Cochran, PT, DPT, GCS, MA, and Gail M. Jensen, PT, PhD, FAPTA

INTRODuCTION

Inthecurrentdynamichealthcareenviron-ment, patients often present with numerouscomorbidities within a multifaceted socialandeconomiccontext,whileinsurerscontin-uetolimitpaymentfornecessaryservices.Inordertomeetclinicalpracticedemands,edu-catorsareresponsibleforclearlyunderstand-ing the development of clinical reasoningabilitiesandfacilitatingstudentdevelopmentofstrongclinicalreasoningskills.

Clinical Reasoning

Understandingtheclinicalreasoningprocessis challenging, given the complexity of fac-torsthatcontributetothereasoningprocessandthevarietyofdefinitionsthatexistinthehealthprofessions literature.1-3Forexample,clinical decision making, critical thinking,andclinicalreasoninghavebeenusedinter-changeably to describe the same phenom-enon. For the purposes of this paper, theauthors chose to operationally define theseterms.Inthebroadestandmostgeneralsense,clinicalreasoningcanbesummarizedasthethinkinganddecisionmakingofahealthcareproviderinclinicalpractice.4Essentially,clin-icalreasoningis thecritical thoughtprocessand judgmentbehindone’saction,5whereasclinicaldecisionmakingistheactionthatistakenonthisprocess.6Tobetterunderstandthisdifference,itmaybehelpfultothinkthatonecanmakeadecisionwithoutanyreason-ing or thought process behind that choice.Nikipoulou-Smyrni and Nikopoulos defineclinicalreasoningasareflectiveprocessthatengages thepatientandfamily incollabora-tivedecisionmaking,takingintoaccountthecritical contextual factors to determine an

Jennifer Furze is an associate professor in the Department of Physical Therapy at Creighton University, 2500 California Plaza, Omaha, Ne-braska, 68718 ([email protected]). Please address all correspondence to Jennifer Furze. Lisa Black is an associate professor and director of clinical education and residency programs in the Department of Physical Therapy at Creighton University. Julie Hoffman is an adjunct associate professor in the Department of Physical Therapy at Creigh-ton University. JB Barr is an associate professor in the Depart-ment of Physical Therapy at Creighton Univer-sity. Teresa M. Cochran is a board-certified specialist in geriatric physical therapy and currently prac-tices at Peterson Physical Therapy, PC, Omaha, NE. Gail M. Jensen is the dean of the Graduate School and University College, vice provost for learning and assessment, and professor in the Department of Physical Therapy at Creighton University. This study was approved by the Creighton Uni-versity Institutional Review Board.This research was supported in part through a Creighton University Office for Academic Excel-lence and Assessment grant fund. The authors declare no conflicts of interest.Received November 15, 2012, and accepted February 25, 2013.

Ninety-eightstudentsfrom2consecutiveclass cohorts participated. Low inferencedata fromtheClinicalReasoningReflec-tionQuestionnaire(CRRQ)andnarrativecommentsfromtheClinicalPerformanceInstrument (CPI) were analyzed usingthe constant comparative method. Opencodingwasusedtoinitiallycategorizethedata followed by axial coding to identifyresultingthemes.Results. Threecategories (beginning, in-termediate,andentry-level)and8themesemergedfromthedatadescribingstudentdevelopment of clinical reasoning skills.Thefollowingthemessurfacedunderthebeginningclinical reasoningprocesscat-egory: focus on self, compartmentalizedthinking, and limited acceptance of re-sponsibility. Themes in the intermediatecategory were: procedural performance,initial stages of recognition and usingcontext,and improvedreflectiononper-formance.Themesinthefinalentry-levelcategory were: dynamic patient interac-tionandintegratingsituationalawareness.Discussion and Conclusion. The resultsofthisstudydemonstrateaprogressioninthe development of these students’ clini-calreasoningprocessaroundthedimen-sions of self, context, and responsibilityacross the curriculum. Outcomes revealthesekeyaspectsoftheclinicalreasoningprocess: (1) it is a gradual developmen-tal process across time; (2) the Dreyfusmodelofskillacquisitionmayapplytothedevelopmentofclinicalreasoningskillsinphysicaltherapystudents;and(3)increas-ing intensity and depth of the reflectiveprocess may be a critical component intheadvancementoftheclinicalreasoningprocess.Furtherresearchisneededtode-terminethebeststrategiestoassessclini-calreasoningabilitiesinphysicaltherapystudentsandtodiscernapproachestoen-

Background and Purpose. Given thecomplexityofthecurrenthealthcareen-vironment, effective clinical reasoningskills are fundamental to making criticalpatientcaredecisions.Thepurposeofthisstudy was to explore the clinical reason-ing abilities of students across time in 1professional Doctor of Physical Therapy(DPT)curriculum.Methods.Qualitativemethodswereusedto describe the longitudinal develop-mentofstudents’clinicalreasoningskills.

hancethislearningprocess.Key Words: Clinical reasoning, Studentlearning,Professionaleducation.

Vol 29, No 3, 2015 Journal of Physical Therapy Education 23

appropriateclinicalintervention.7Usingthisdefinition, one can see both contextual andcognitiveaspectsofclinicalreasoning.Con-sistent with other definitions, critical think-ing would be a component of the cognitiveaspect of clinical reasoning.8 Critical think-ingasacognitiveskillinvolvesinductiveanddeductivethinking,evaluation,andanalyses,but does not encompass judgment, reflec-tion,orthemanycontextualfactorsthatareapartofclinicalreasoning.8Clinicalreason-ingiscomplexbecauseitinvolvestheapplica-tionofcognitive,affective,andpsychomotorskillswhileusingareflectivethoughtprocesstomakedecisionsandjudgmentsbasedonapatientpresentation.9

Emphasisonclinicalreasoningineduca-tionhasbeenreportedinmedicine,dentistry,occupational therapy, physical therapy, andnursing.10Infact,theAmericanAssociationofCollegesofNursing(AACN)hasstressedthe importance of developing and assessingclinical reasoning skills in nursing studentsaspartofnursingeducation.11Arecentcallforradicaltransformationinnursingeduca-tionincludesanemphasisonclinicalreason-ing and multiple ways of thinking, whichwillenablenursestopracticesafely,compas-sionately,andaccuratelyindifferentpracticesettings.12 Similarly, the American PhysicalTherapy Association (APTA) also identifiesclinical reasoningas a skill andpractice ex-pectationdescribed in theNormative Model of Physical Therapist Education,13yetacom-prehensive approach for facilitating and as-sessing clinical reasoning across physicaltherapy education programs has not beenclearlyestablished.4

The advancement of any skill is devel-opmental in nature and requires practiceover time. Dreyfus and Dreyfus proposeda framework of skill acquisition that maybe applicable to the development of clinicalreasoning abilities in physical therapy stu-dents.3,14,15 This model has been applied inmedicine and nursing to describe variousbenchmarks(novicetoexpert)alongthecon-tinuumofclinicalskilldevelopment,aswellas key characteristics/traits associated witheach level.16,17TheDreyfusmodeloriginallydescribed the developmental model of skillacquisition when observing the progress ofpilotsandchessplayersovertime.14,15Inthemodel, the learner passes through 3 phaseswhenmovingfromnovicetoexpert.3Duringthefirstphase, the learnershifts fromusingabsoluterulestoincorporationofpastexpe-riencestoguidedecisionmaking.Thelearnerthen moves away from gathering unrelatedbitsof informationtocohesively“seeingthebigpicture”inthesecondphase.Finally,thelearnerbecomesanintegralpartofthesitu-

ationandnolongerviewshimself/herselfasanisolatedcomponentoutsideoftheexperi-ence.3 The evidence in the physical therapyliterature about clinical expertise suggestsexpertsrelyonpastexperiences,patternrec-ognition,andsynthesisof importantpatientinformationtomakedecisions.18Specifically,Jensenandcolleaguessuggestthataclinician’sapplication of knowledge and skill, pairedtogetherwith the intuitiveability tovaryanexaminationortreatmentbasedonreflectiveproblem-solvingandpatientinteraction,dis-tinguishes a novice from expert clinician.19Basedontheaboveinformation,theDreyfusmodelcouldbeaguidingframeworkfordataanalysisinlookingatbenchmarksforskillac-quisitionastheyapplytoclinicalreasoning.

Assessment of Clinical ReasoningAlimitednumberofmethodsandtoolsexistintheliteraturetoassesstheclinicalreasoningabilitiesofstudentsinthehealthprofessions.Someoftheseinstrumentsincludethescriptconcordance test (SCT), concept mappingconstructs,thinkaloudtechniques,quantita-tive standardized tests, and qualitative mea-suresofwrittenreflection,interview,orfocusgroupresponses.3,20-23TheSCTisfrequentlycited in the medical education literature asatooltoassessclinicalreasoningabilitiesofmedicalstudentsandresidentsinambiguousanduncertainsituations.20,24-27Thistestcom-paresthetesttaker’sabilitytomakedecisionsandinterpretationsusingmultiplesourcesofdatawhilecross-referencingtheseinterpreta-tionstoanexpertpanel.28TheSCTwasusedinphysical therapy toassessknowledgeandreasoningabilityaroundseatingandmobilityprescription.Theauthorsfoundthatalthoughthetestwasabletodifferentiateexpertsfromnovicesinthisarea,itwaschallengingtode-terminetheappropriatemeasuresorcharac-teristicsofaseatingandmobilityexpertuponwhich to base the test.29 Concept maps areanothertooltomeasureandfacilitateclinicalreasoning abilities of students in the healthprofessions, particularly in dentistry andnursing.30,31 The purpose of a concept mapisdesignedtohelpstudentslinkconceptsto-getherinaneffortto“visualize”thethoughtprocess and content knowledge. In additiontoconceptmaps,thinkaloudtechniquescanalsohelptheeducatortoseethestudents’rea-soning process.21 Standardized instrumentsformeasuringgeneralcriticalthinkingskillshavebeenappliedtopredictreasoningcapac-ityinphysicaltherapystudents.32-39However,these tests are only able to assess a singlecomponentof theclinical reasoningprocessandthereforemaynotaccuratelyreflecttrueclinicalreasoningability.TheHealthSciencesReasoningTest(HSRT),specificallydesignedtoassesscriticalthinkingskillsforhealthpro-

fessionstudents,wasfoundtobemorevalidineliminating theceilingeffects foundwithothertools, includingtheCaliforniaCriticalThinkingSkillsTest(CCTST).8Nevertheless,the authors of this study found this singletesttobeinadequateinassessingclinicalrea-soning skills, as it primarily measures only1 component of clinical reasoning (criticalthinking) and doesn’t address other contex-tualvariables.8Studiesperformedinnursingeducationsuggestthatthecomplexityofclin-icalreasoningistoonarrowlydefinedbysuchquantitativeassessmenttools.40Theseinstru-ments attempt to objectify critical thinking,buttotrulyexploretheprocessofdevelopingclinical reasoningskills,qualitativemethodsincorporatingreflectionareneeded.3,22,33

Whilethedisseminationofresearchfind-ingsevaluatingclinicalreasoningskillsinthehealthprofessionshasprimarilyoccurredinnursingandmedicalliterature,littlehasbeenstudiedinphysicaltherapytoassessthisskilldevelopmentovertime.10-14Inthisinvestiga-tion,facultywantedtoascertainthedevelop-mentofcurrentclinicalreasoningabilitiesofstudentsastheymovedthroughtheprogram.Oncethiswasdetermined, facultymemberswereinterestedinusingthisevidenceofstu-dentlearningtoinformtheirteachingstrate-gies.Thepurposeofthisstudywastoexplorethedevelopmentofstudentclinicalreasoningabilitiesovertimein1professionalDoctorofPhysicalTherapy(DPT)program.

METHODS

Project designQualitativemethodswereutilizedtoexplorethe longitudinal development of studentclinicalreasoningcapabilitiesacrossthecur-riculum at 1 professional DPT program inthe Midwest. Specifically, written studentresponses to a Clinical Reasoning Reflec-tionQuestionnaire(CRRQ)wereusedastheprimarydata source,coupledwithnarrativeresponsesfromtheClinicalPerformanceIn-strument (CPI) as a secondary data sourceandtriangulationofthecorethemes.

Curriculum InfrastructureDescriptionofthesystems-based,integratedlifespan curriculum model is needed to un-derstandthetimingofdatacollection(Figure1).Beginningwiththefoundationalsciencesand essential clinical skills coursework, thecurriculum progresses to include clinical,integrative,andcontextualsciences.Clinicalexperiencesareinterspersedbetweensemes-ters,culminatinginfull-timeexposureattheend of the curriculum. Case application tofacilitateclinicalreasoningskills is threadedthroughout the curriculum, beginning withbasiccasesearlyinthecurriculumandpro-


gressingincontextandcomplexityovertime.To confirm student safety and competenceinpatientmanagement,theClinicalCompe-tence Performance Examination (CCPE), apractice-basedcasesimulationinwhichfac-ultyservedualrolesaspatientandevaluator,wasadministeredattheendofeachacademicsemester prior to participating in a clinicalexperience.

Participants

StudentsingoodacademicstandingenrolledintheprofessionalDPTprogramatCreigh-tonUniversityinOmaha,Nebraska,wereeli-

gible for inclusion in thestudy.All studentswererecruitedviaemailinvitationatvaryingpoints in thecurriculum,which spans8 se-mestersacross3calendaryears (Table1).Atotalof98studentsfrom2consecutiveclasscohortsparticipatedinthisstudy.Forty-ninestudents were recruited in semester 6, and10 in semester8 fromClassB.ForClassA,49 students participated in semester 4, 48in semester 6, and 8 in semester 8 (Table2).During the initialphaseofdataanalysis,theneedtocaptureparticipant insightatanearlierpointintimeemerged.Therefore,theinvestigators collected data from Class A in

semester4butwereunabletodosoforClassB, as these students had already progressedinthecurriculum.Insemester8,apurposivesamplingmethodwasusedtorecruitstudentparticipants, on account of the curriculumnot requiring a CCPE component at thatpointintime.Sixteenparticipantsrepresent-ingarangeofacademicandclinicalabilities(low to high GPA, successful to exemplaryscoresonCCPEandCPI)wereembodiedinthesample.Thespecificprocessandtimelinefor collection of student participant data isfurtherdescribedintheproceduresection.

Data Collection Instruments

Thepurposeofthisstudywastoexploretheclinicalreasoningskillsofprofessionalphysi-cal therapy students across the curriculum.However, few qualitative valid and reliablemechanisms exist to assess this skill set inphysical therapy. Therefore, the CRRQ wasdeveloped to identify andassess theseabili-ties.Inaddition,theCPIwasusedtocollectdataduringtheexperientialphaseofthecur-riculum.Clinical Reasoning Reflection Questionnaire (CRRQ).TheCRRQ(AppendixA)isa6-ques-tion,onlinesurveydevelopedbythecurrentinvestigators to facilitate depth of reflectiveresponse. Its constructionwasbasedonkeytheoretical constructs in clinical reasoningresearch41-44and expertise in survey design.Amajorchallengeinassessmentof learningis finding ways to uncover and understandthe diversity of reflective processes used bystudents. Using dimensions of the Interna-tionalClassificationofFunctioning,Disabil-

Figure 1. Creighton University Professional Doctor of Physical Therapy (DPT) Curriculum

Table 1. Timeline of Data Collection Across Curriculum

Semester 4 Semester 6 Semester 7 Semester 8

Clinical Reasoning Reflection Questionnaire

Class A (n = 49) Class A (n = 48)Class B (n = 49)

Class A (n = 6)Class B (n = 10)

Clinical Performance Instrument

Class A (n = 49)End of a 3-week clinical experience

Class A (n = 48) Class B (n = 49)Week 10 of a 20-week clinical experience

Class A (n = 48)Class B (n = 49)End of a 16-week clinical experience

Table 2. Participant Demographics

Participants Average Age

Baccalaureate Degree Prior to Admission

Gender Ethnic Background Number of Participants

Class A 23 79% Male = 33%Female = 67%

Asian = 4%Black = 4%Caucasian = 92%

(n = 49) semester 4(n = 48) semester 6(n = 6) semester 8

Class B 23 77% Male = 27%Female = 73%

Asian = 2%Black = 2%Caucasian = 96%

(n = 49) semester 6(n = 10) semester 8


ityandHealth(ICF)framework45tobroadenstudent perspective of patient management,questionswerecraftedaroundcoreconceptsincluding (1) metacognitive thinking,41 (2)struggling with uncertainty,42,43 and (3)critical self-reflection and growth. Students’metacognitive skill was addressed by askingtheparticipantthefollowing:“Describeyourthoughtprocessandinitialimpressionsaboutthe selected case you’ve been given for theclinical competence performance examina-tion.Whatdoyouthinkthepatient’spriori-ties fromthephysical therapist’sperspectivecould be that you would want to address?”(CRRQpresurveyquestion#2).Thestudentprovides evidence of his or her metacogni-tiveprocess(disclosingthethinkingprocessby“gettingtheinsideout”)justaselementarystudents might outline steps in solution ofa math problem. The second core constructcenteredontheconceptdescribedinmedicaleducation as “struggling with uncertainty.”46Experiential learning theories suggest thatstruggling in a dynamic environment andbeingchallengedtoreachbeyondone’scom-fortzonewithguidedreflectioncanfacilitatestudentlearning.47,48Thiscoreconstructwasillustratedbythefollowingquestion:“Basedupon your interaction with the patient dur-ingthephysicaltherapyexaminationandin-terventionpieceoftheClinicalCompetencePerformance Examination, how did youmodifyyourplanofcareorapproachtothispatient?”(CRRQpostsurveyquestion#2).Inthiscase,thequestionencouragesthestudenttodiscussthedifficultyinthinkinginanewandchallengingenvironmentversusthetra-ditionalapproachofaskingfortherightan-swer. Another core concept embedded intothisquestionnairewascritical self-reflectionand growth, a concept described in the fol-lowingquestion: “If youwereable to repeatthis Clinical Competence Performance Ex-amination experience, what would you dodifferently and why?” (CRRQ postsurveyquestion#1).Thisquestionfacilitatesreflec-tion and allows the student to demonstrateanypersonalorprofessionalgrowththatmayhaveoccurredasaresultof this interaction.Theremaining3questionsweredevelopedtodeterminethestudents’abilitiestoapplytheICFframeworktothepatientandtodescribetheirclinicalreasoningprocess.45

Initially,theCRRQwaspilottestedwithacoregroupoffaculty(n=5)andstudents(n=5)andthenrevisedbasedonfeedback.Onequestionwasmodifiedtoexplicitly labelthecomponentsofthephysicaltherapyexamina-tion,ask theparticipants toprovide specificexamples, and justify rationale to better re-vealtheparticipant’sthoughtprocess(CRRQpresurvey question #3). Another questionwas changed to specifically label and define

personal factors for the participant to avoidconfusion and to ask “how” the participantmodified theplanof care to capturepartofthe reasoning process (CRRQ postsurveyquestion #2). Three female physical therapyfacultymembersand2maleswithexpertisein survey development piloted the surveyduringtheCCPEtodeterminestudentfeasi-bilityandabilitytogatherthoughtprocessesduringthisexamination.Threefemaleand2malephysicaltherapystudentsintheirthird(outof4)yearintheprogramalsocompletedthequestionnaireandprovidedfeedbackforareasofclarityandreadability.Clinical Performance Instrument. The CPIisthemostcommonlyused toolbystudentsandclinical instructors (CI) toevaluatestu-dent performance during a clinical experi-ence.49NarrativecommentschosenfromCPIitem #7 (labeled “Clinical Reasoning”) wereusedinthisstudyasanadditionaldatapointtoprovidetheCI’sexternalperspectivedur-ing participant clinical experiences (Appen-dixB).

Procedure

There were 2 class cohorts that participatedinthisstudy(Table1).AllmembersofClassB were allowed 20 minutes to complete thecomputerized CRRQ immediately prior tointeractingwithasimulatedpatientaspartoftheCCPE.Immediatelyfollowingthesimula-tionexperience,participantswereallottedanadditional20minutestocompletetheCRRQreflectionquestions.Thisprocessoccurredattheendofsemesters6and8ofthecurricu-lum. Investigators then reviewed CPI datafromthemidterm(week10)ofthe20-weekclinicalexperiencethatfollowed(semester7).Attheendofsemester8,10participantsfromClass B again completed the CRRQ beforeand after completion of a simulated patientexamination(similartotheCCPE).CPIdatawere reviewed upon completion of the finalclinical experience (semester 8). One yearlater, allmembersofClassAcompleted theCRRQusingthesamedatacollectionprocessbeginning at the end of semesters 4, 6, and8.CPIdatawerethenreviewedattheendofthe3-weekclinicalrotationthatimmediatelyfollowedtheendofsemester4.CPIdataforClassAwereagainreviewedatthemidterm(week10)ofthe20-weekclinicalexperiencethat followed (semester 7). Additionally, 6participants from Class A completed theCRRQprocessattheendofsemester8,andtheircorrespondingCPIdatawerereviewed.Throughout thisprocess, theCPIdata fromeithermidtermorfinalthatweremostcloselyalignedintimeframetotheCRRQwereusedasadatapoint.Table1outlinesthetimelineofdatacollectionacrossthecurriculum.

Data Analysis

All narrative responses from students(CRRQ)andCIs(item#7onCPI)weregath-ered via computer transcripts for analysisand triangulation of data sources. The lowinferencedatafromtheCRRQandCPIwereanalyzed using the constant comparativemethod.50 During the open coding phase, 5investigatorswhowere involvedwithall as-pects of project conceptualization and datacollectionreviewedalltranscriptsandgener-ated initial codes independently. Open cod-ing consisted of identifying common keywords,concepts,andwordphrasesfromthedatasources.50-52Thepreliminarycodeswerethen analyzed until saturation was reachedand concepts were sufficiently categorized.Axialcodingwasperformedby the5 inves-tigatorsduring6meetings inwhich theau-thorscollectively identifiedthecorethemes:focus on self, compartmentalized thinking,limited acceptance of responsibility, proce-duralperformance, initial stagesof recogni-tion using context, improved reflection onperformance, dynamic patient interaction,and integrating situational awareness. Thesethemes emerged during analysis and con-sensusbuildingacross the initial codedcat-egories,whileatypicalcases that failedtofitinto established categories continued to bediscusseduntilagreementwasreached.53,54Afinalstepgeneratedadatamatrixtoidentifyrelationshipsamongthecategories.55

Trustworthiness of the Study

Inaddition to theuseof low inferencedataandtriangulationofstudentandCIdata,sev-eralstandardsofverificationwereusedtoen-hance the study’s methodological rigor. Theresearchteamconsistedofprofessionalsfromdidacticandclinicaleducation,academicad-ministration, and clinical specialties in car-diovascularandpulmonary,orthopedic,andpediatricphysicaltherapy.All5investigatorsparticipated in the entire research projectfromconceptualdesigntodatacollectionandanalysis, allowing triangulationof investiga-tor coding during data analysis. Bracketingefforts identified the investigators’ precon-ceived assumptions about the topic area sothat potential bias could be recognized. Toaccomplishthis,theauthorsattemptedtoim-prove their reflexivity by discussing percep-tions that might influence coding and dataconceptualization. Among the investigators,the concepts that could potentially bias thedata interpretationincludedlevelofrespon-sibility, comparison of professional studentsto residents, paternalistic perspective, biasas professional educators, and unrealisticgraduate-level expectations. Finally, a sixthinvestigatorwhohadnoinvolvementinini-


tial data collection, but who possessed ex-pertiseinqualitativeresearchandgeriatrics,performedanexternalauditofthedata.

RESuLTS

Participants

Data indicated that participants progressedintheirclinicalreasoningprocessacrossthecurriculum,beginningwithastrongfocusonself and procedural skills then transitioningtoward a focus on the needs of the patientandanemergingsituationalawarenessbytheend of the curriculum. Analysis specificallyrevealedashiftinfocus(internaltoexternal),emergingcontextualawareness,andreason-ingability(rigidtoflexible),whichresultedinprogression from beginning, through inter-mediate,toprofessionalstagesoftheclinicalreasoningprocess(Table3).

Anotherreplied:I would have practiced more with spe-cific interventions and my reasoning for those interventions. I had good ideas of what I wanted to do, but I could not back up everything with a purpose, even though one may have existed.

These responses indicate participants are intheearlyphasesoflearningaskill,astheyarefocusedontheirindividualperformancever-sustheimpactonthepatient.Compartmentalized thinking. This themerevealed participants’ rigidity in thoughtprocess and inability to integrate informa-tion. Participants seemed to complete testsandmeasuresasamatterofroutinewithoutrespondingtoanythingthepatientwasdem-onstratingorsaying.Whenaskedwhatmightbe done differently next time, 1 respondentstated:

I was too busy going through the check-

Beginning Clinical Reasoning Process

ThreethemesemergedfromtheCRRQdataearlyinthecurriculumduringsemester4(n=49): (1) focusonself, (2)compartmental-ized thinking,and (3) limitedacceptanceofresponsibility.Focus on self.CRRQreflectionscenteredonwhatthestudentmighthavedonetoimproveperformance without recognizing patient-centered issues. For example, when asked,what would you do differently in the futureif you could repeat this experience again, 1respondentstated:

I think that I prepared very well for this practical which is why I was confident in my skills and performed well. The 1 area that I need to improve on is my effi-ciency. I had the patient repeat positions because I forgot to complete certain tests and measures.

Table 3. Data Matrix: Relationships of Themes

Curricular Timing Beginning Intermediate Entry-Level

→ →Participant Focus

Internal Emerging contextual External Rigidity Creativity and flexibility Egocentric responsibility Patient-centered responsibility

Focus on Self

Evaluates own performance

Shows little awareness of patient issues

Initial Stages of Recognizing and Using Case Context

Begins to consider contextual factors (age, environment, situation)

Demonstrates difficulty adjusting to unexpected findings

Dynamic Patient Interaction

Demonstrates flexibility in patient examination

Listens and observes more actively

Reflects on performance during patient interaction

Compartmentalized Thinking

Driven by routine and rigid thought process

Performs components of examination as isolated “boxes” of familiar information

Unable to integrate information

Procedural Performance

Focus on physical therapy examination (tests and measures) component of patient management

Completes scripted examination

Unable to see the “big picture” and incorporate components of the International Classification of Functioning, Disability, and Health (ICF)

Emerging Evidence of Situational Awareness

Recognizes and applies contextual information

Identifies and considers individual patient factors

Limited Acceptance of Responsibility

Blames outside factors for own mistakes

Fails to identify weaknesses

Improved Reflection on Performance

Evaluates own performance more meaningfully

Recognizes mistakes and plans for future changes


list in my head, and I wasn’t listening to the patient. I felt like I could have come to the diagnosis a lot sooner if I was lis-tening instead of worrying about what my next test would be.

Adifferentrespondentexplained:I wouldn’t have stopped myself when I did. I pigeonholed the neuromuscular system as the testing of nerves only and did not assess function, so I never got the patient out of the chair…I was stuck in my mental box.

In these cases, the participants describe arigidthoughtprocessintheirapproachtopa-tientmanagementwhencategorizingpatientsinto“boxes.”

ThedatafromtheCI’sviewpoint,asgath-eredfromitem#7ontheCPI,indicatedthatstudentsatthislevelhaddifficultyorganizingdatafrompatientsandunderstandinghowtointerpretpatientdata.Forexample,1CIcom-mented, “He has trouble determining whentoperformneurologicdiagnostictestingandthemeaningofthisinformation.”

This statement supports the theme ofcompartmentalizedthinking,asstudentshaddifficulty integrating data as they arbitrarilyboundtheresultsof testsandmeasuresandwere unable to access that information tohelpthepatient.Limited acceptance of responsibility.Thirdly,externalattributionofblameforstudentmis-takes was evident. When asked what mightbedonedifferentlyiftheexperiencecouldberepeated,arespondentindicated:

I think the main thing I would do dif-ferently is bring in children to be the pa-tients for the pediatric cases. I think that it is very subjective to assume whether or not the student is able to work well in pediatrics by basing that judgment on their interactions with an adult acting like a child.

Adifferentrespondentindicated:The only other thing I would change is maybe the instructors’ assistance before the exam. Some instructors, when pre-sented with questions about the mate-rial, were so vague that it did not answer the questions at all. I understand that their goal is to not give away too much information, but I feel that if a student has studied enough that they are asking a well-educated question, the instructor should respond to that question with a thorough, complete answer.

Anotherstated:I would be more prepared in studying other diagnoses, in addition to what was in the lab handouts. I had briefly studied the musculoskeletal notes but was not

expecting subacromial bursitis since we did not cover it in lab. In these examples, the participants did

not identify their own areas of weakness inperformance.Rather,theyprovidedexternalattributionfordeficits.

Outlier Cases

While many participants in the beginningclinical reasoning group struggled to focusbeyondtheirownpsychomotorperformance,afewstudentsdiddemonstrategreaterdepthofreflection,indicatingthattheywouldfocusmore on the patient’s needs. For example, 1studentstated:

I would change my exam so that I played with the child first, which would (1) build a relationship of trust between us, and (2) allow me to observe as she played, which would allow me to focus in on what it is that I would need to look at for my examination. I need to be more imaginative with my interventions, espe-cially for children, so that they are func-tional as well as fun for the child.

This respondent is beginning to identifyplayandfunasimportantfactorstothechild,indicating an emerging shift away from selfandtowardthechild’sneeds.

A comment from the CPI data supportsthe notion that a few students were able toemphasize the patient’s needs rather thantheir own. For example, 1 CI stated, she“demonstratesanunderstandingoftheneedtoestablishgoalswithpatient/familyinput.”

Another participant took full account-ability for his/her performance during theexamination,contrarytothethemeofblam-ingothers,asevidencedbythefollowingre-sponse:

Well, I failed the neuro part of the exam, but I deserved to fail it. I was not fluid with my overall examination and the flow of my testing was choppy. I forgot several important factors of the exam, including testing blood pressure, range of motion, and bed mobility. When I did remember them, it was during a point that made it awkward for testing. Over-all, I am glad that I have to take it again because I do need to perform better, and it will help me learn.

While the frequency of these responseswas not great enough to categorize as atheme,theyareworthmentioningsincetheyofferadifferentperspective.

Intermediate Clinical Reasoning Process

Asdescribedearlier,dataearlyintheclinicalreasoning process revealed that participants

were focused on their own individual per-formance and unable to incorporate patientinformation into the process. However, asprogression through the curriculum oc-curred,participantsbegantoincorporatepa-tient information into theclinical reasoningprocessandplanning. Threethemesemergedfromthedatacollectedinsemester6(n=97)in the curriculum. These themes included:(1) a focus on procedural performance bystudents,(2)anabilitytousetheinitialstagesofrecognizingandusingcontextwhenevalu-atingapatient,and(3)evidenceofimprovedreflectiononhisorherperformance.Procedural performance. Proceduralperfor-mancewasanemergingthemethatindicatedparticipantswere focusedonspecificproce-dural aspects of patient management with-out recognizing the importance of contextandallcomponentsoftheICFmodel.Whenasked to describe an initial thought processandanticipatepatientprioritiesbasedoncaseinformation, a participant responded, “Myprimaryareaoffocusforthispatientwillbetoaddresshiskneepainandlookforaphysi-calcause.” Participantswerealsoaskedafterthe experience to describe what they woulddodifferentlyiftheywereabletorepeatthisinteraction again. One explained, “I wouldmakesuretodoallthescreeningtechniques,especially for the hip because I forgot that.”Atthispoint,participantsexhibitedtheabil-ity to identify basic or foundational com-ponents of the patient management processrelatedtoperformingtestsandmeasures,butwereunabletoseethe largerpatientpicturethatwouldencompassallofthecomponentsoftheICFmodel,includingtheimpactonapatient’s ability to participate in activities ofdailyliving(ADLs)andcontributetosociety.

Thedata fromtheCPI revealed that stu-dents had difficulty incorporating patientfactors, other than textbook information,into their reasoningprocess.Forexample,1CI commented, the student is challenged to“developaplanofcarespecifictothepersonratherthananinjury.”Initial stages of recognizing and using case context.Duringsemester6,participantswerebeginningtoidentifytheneedtoincorporatecontextualfactorssuchasage,environment,and situation into the patient managementprocess with “basic, straight-forward cases.”In addition, they could envision a predeter-mined“picture”ofthepatientbasedoninitialcaseinformation,buthaddifficultyadaptingto information thatwasdifferent from theirexpectations. When participants were askedhow personal factors, including patient be-liefs,perspectives,culture,attitude,socioeco-nomicstatus,andeducationwouldimpacttheplanned physical therapy examination and


intervention,1respondentreported,“IthinkI need to take into consideration that Brianisnotanadult,andperhapswillnotbeabletogiveacomplete subjectivehistoryaswellasIwouldlike.”Thisresponsedemonstratesrecognitionthatageandsomesituationalfac-tors will be important considerations in thepatientexamination.Whenaskedtodescribewhat they would do differently next time, aparticipatedresponded:

I would be more organized with my ob-jective exam. I went in expecting one thing and then almost immediately dur-ing the exam it presented as something else and I didn’t know what to do.

This response highlights the challenge theparticipantshadinadaptingtodifferentpa-tientpresentations.

The CPI data from the CIs’ perspectivessupportthethemeoftheinitialstagesofcasecontext.Thesedatasuggestthestudentsdem-onstratesomeproficiencyinutilizingasoundclinical reasoning process with “straight-forwardcases,”buthadmoredifficultywith“complex conditions.” One CI stated: “Sheneeds assistance 20% of the time to synthe-sizedatafrommultiplesourcesinto1pictureandtreatmentplan.”Anotherresponded,“Hecontinuestorequiresomecueingtoproblemsolvecomplexsituations.”Adifferentinstruc-tor explained, “He was able to consistentlyperformgoodclinicaldecisionmakingwithstraight-forward diagnoses, but needs helpswithmorecomplexpatients.”Improved reflection on performance. Thefinalthemetoemergeduringtheintermedi-ate reasoningprocess suggestedparticipantsdemonstrated an improved reflective capa-bilityaftertheirinteractionwiththepatient.Whenaskedwhatcouldbedonedifferentlyinthefuture,aparticipantresponded,“Iwoulddomoretomakethepatientcomfortableandtrustingofme.”Anotherstated:

I would organize my examination ac-cording to the patient instead of having a specific plan. I planned for the patient to be positioned in supine and when he came in his wheelchair, I didn’t have a plan anymore. I would have been more flexible according to the patient.

Inaddition,1participantindicated,“Iwouldbemorehands-onwiththepatienttoletthemknowIamthereforthem.”Theseresponsesdemonstrate “reflection-on-action,”56 whereparticipants were able to reflect on the ex-perience after the interaction, helping themdetermine changes they would make in thefuturewheninteractingwithsimilarpatients.

Data from the CIs indicate students atthislevelwereabletoreflectonthesituationandmakeappropriatechangestopatientcare

plans.OneCIstated,“sherecognizedhercur-rent experience limits and would seek helpwhen needed,” demonstrating the student’sabilitytothinkaboutherskillset,identifytheneedforadditionalhelp,andtakeappropri-ateaction.

Outlier Cases

Once again, a small minority of students inthe intermediate clinical reasoning stagerecognized that they should treat the wholepatientandmustadapt thephysical therapyexaminationandinterventiontomeetthepa-tient’sneeds.Forexample,1participantcom-mented, “Iwould focuson the largepictureinstead of each individual piece.” Anotherreportedthathewould“listentothepatientto understand his or her perspectives andbeawareandsensitivetothem.Youhavetomeetthepatientwheretheyare.Ifthepatienthascertainbeliefs,youhavetorespectthose.”These participants are articulating a focusawayfromtheirownindividualperformanceasastudenttherapistanddirectingtheirat-tentiontothepatient’sneeds.Thiswasnotacommonresponseinsemester6data.

Entry-Level Clinical Reasoning Process

The following 2 themes emerged from thedata collected in semester 8, just prior tograduation:dynamicpatient interactionandevidenceof integratingsituationalawareness.In the beginning and intermediate clinicalreasoning process groups, participants weremovingfromafocusonselftoincorporatinginformationfromthepatientintotheirclini-calreasoning.Participants intheentry-levelgroup routinely integrated patient data intotheirclinicalreasoningprocessandbegantoapplythisinformationindifferentsituations.Dynamic patient interaction. Dynamic pa-tient interaction was a theme implying thatparticipantswereflexibleandabletochangedirection during the patient examinationbasedonverbalornonverbalresponsesfromthe patient. This included active listeningandanability toask thepatientappropriatequestions,aswellas theability toanticipatetheunknown.Inaddition,participantuseofreflection-in-action, or changing one’s be-haviorinresponsetopatientcuesduringtheencounter,isanimportantcomponentofthistheme.34,56 For example, when asked, “Howdidyoumodifyyourplanofcareorapproachtothispatient?”aparticipantanswered,“Halfwaythroughtheexam,thepatientmentionedsomething about having dizziness. I dovefurther into this, differentiating betweendizziness, light-headedness, and spinningsensation.”Anotherresponded:

Based on the patient case, it seemed like

I was going to be focusing on gait and his limitations. However, during the inter-view it became clear that his left upper extremity was more the concern from his perspective. Therefore, I focused on the shoulder and upper extremity.

This statement suggests the participant en-gagedin“reflection-in-action,”56ahigh-levelskill requiring assimilation of informationfromthepatientthatchangestheparticipant’scourse of action during the patient session.When responding to presurvey question #1(Howwillpersonalfactorsbeapartofyourplanned physical therapy examination andintervention?),aparticipantstated:

The most influential component at this point will be what the patient brings to the table, what is most important to them, what do they perceive as chief complaints, their beliefs about needing to improve.

Theserepliesindicatethattheparticipantsareabletonotonlyengageinactivelistening,butalso alter their own actions in determiningtests,measures,andinterventions.

DatafromtheCPIsuggeststudentswereabletochangetheplanofcarebasedonthepatient’s response. One CI reported, “Thestudent recognizes when the plan of care istoo simple or too challenging and quicklyadaptstomeettheneedsofthepatientwithinthat session.”Here, theCI is identifying thestudent’sabilitytodemonstratereflection-in-action56asahigherlevelofreflection.Integrating situational awareness.Thisthemerepresents participant ability to recognizeandapplycontextual informationto thepa-tient management process and relate to the“patient’s story,” demonstrating narrativethinking. When asked about modifying theplanofcareorapproachtothepatient,1re-spondentanswered:

Since my patient has a fear of falling, I asked her about that issue. She pointed out her cat got in her way and getting out of the shower was difficult. I asked about any rugs and lighting. I provided education on limiting rugs and uneven surfaces, and good lighting to reduce the risk of falls. I also assured her that she had pretty good balance at this point, and provided education on activities that can be incorporated at home to im-prove her current balance abilities.

Anotherresponded:I would have asked the patient more questions about his ability to perform ADLs such as cooking, laundry, dressing, bathing, and about the family support that he identified as important to his independence. This information would


have helped me to identify any problem areas in the future and services.

Inthesecases,theparticipantintegratedpa-tientinformationandmodifiedinterventionsandpreventativestrategiesaroundthisinfor-mation.

TheCPIdatasupportthethemeofemerg-ingevidenceofsituationalawareness.OneCIstatedthatthestudent“involvespatientsandconsiders the family’s values and concernswhen making clinical decisions.” These re-sultsindicatestudentswereabletointegratepatient and family values into the decisionmakingprocess.

Outlier Cases

In contrast to the predominant commonthemes, some respondents did emphasizetheir own performance limitations withoutmovingtowardapatientfocus.Forexample,when asked how the patient managementprocess was modified based on the interac-tionwiththepatient,arespondentstated:

I will review special tests and differential diagnosis information prior to perform-ing an exam. This might make the ob-jective portion flow better and I would feel more confident with the exam tech-

niques after having just reviewed them.Thisresponsewassimilartodatafromthebe-ginnerleveloftheclinicalreasoningprocesswithanemphasizedfocusontheneedsoftheparticipantversusthepatient.

DISCuSSIONThedevelopmentofstudents’effectiveclini-cal reasoning abilities is a critical objectiveof physical therapy professional curricula.Unfortunately, the complicated and cogni-tive nature of the clinical reasoning processpresentschallengestobothteachingandas-sessment of this skill. The aim of this studywastoexplorethelongitudinaldevelopmentofstudents’clinicalreasoningabilitiesacrossthecurriculumtobetterunderstandthisrea-soningprocessandultimatelyinformteach-ingandlearning.Aqualitativeapproachwasusedtoexplorestudentlearningandprovidefacultywithinsightsintothedevelopmentofstudent reasoning abilities at various pointsin time. For these students, we found thatclinical reasoning development occurs as agradual progression across time, and thatthe Dreyfus model of skill acquisition3,14,15

may be a useful framework in categorizingclinical reasoningdevelopment. Inaddition,student reflections, as seen in the themes,

demonstrated a developmental progressioningaininginsightanddepthacrosstime.Thisreflectionmaycontributetotheadvancementoftheclinicalreasoningprocess.

Figure2conceptualizesthedevelopmentalprogressofclinicalreasoningskillsofatypi-cal student over time. This figure highlightsthe gradual nature of this process throughstep-by-step progression from early perfor-mance to professional performance. Thesestepsaresupportedbythethemesidentifiedat each assessment point. Throughout theprogressionofthecurriculum,studentstend-edtomovefromscripted,procedural,self-fo-cusedperformancetoamorefluid,dynamic,patient-focused performance. Henrick et alfoundasimilarprogressionovertimeandatransitionfromsimpleandinternallyfocusedto complex and externally focused conceptsaround clinical reasoning in undergraduatephysical therapystudents inNewZealand.57This focus on self and procedural perfor-manceisconsistentwithotherevidencefromnovice learners.58 Not surprisingly, Babyarand colleagues found that physical therapystudentsself-ratedthemselvesasmoreconfi-dentintheirclinicalreasoningskillsastheyprogressed in the education program.59 Inaddition,studiesdoneinvestigatingthenov-

Figure 2. Conceptual Framework


ice toexpert continuum inphysical therapypracticereinforcesadevelopmentalprogres-sionacrosstime,beginningwithadecreasedawarenessofpatientfactorsandprogressingtoanincreasedawarenessofcontextandpa-tient factors.18,60-63 The work of Jensen et alrevealed expert practitioners utilized a col-laborative clinical reasoningprocess and fa-cilitated patient empowerment to increaseself-efficacy more frequently and effectivelythantheirnovicecounterparts.60

Anotherkeyfindingisthepotentialappli-cationoftheDreyfusmodelofskillacquisi-tion to theprogressionof clinical reasoningskillsinphysicaltherapystudents.Thismodelhasbeenappliedinmedicineandnursingtodescribe various benchmarks (novice–mas-ter)alongthecontinuumofclinicalskillde-velopment,aswellaskeycharacteristics/traitsassociatedwitheachlevel.16,17Wefoundthatthe compartmentalized thinking of an earlylearnerissimilartowhatCarraccioandcol-leagues in medicine describe as a novicelearnerwhousesrulestogovernhisthinking,mustlinkcausewitheffect,andischallengedto integrate and synthesize information.16This inability to see the “big picture” andput the “pieces of the puzzle” together is il-lustratedbytherespondentwhostated,“Ipi-geonholed theneuromuscular systemas thetestingofnervesonlyanddidnotassessfunc-tion.”Lateronintheprogram,studentswereable to demonstrate their ability to under-standmoreaboutthecontextualfactorsthatareimportantinpatientcareandweremoreawareofthesituation(situationalawareness)asacomponentoftheirthoughtprocess.Thetheme of integrating situational awareness,in which participants demonstrated emerg-ing signs of recognizing patterns of clinicalpresentationsthroughcontextandtheabilitytoseethe“bigpicture,”highlightsconceptsofthe “competent” level, as described by Car-raccioandcolleagues.16

The third key point (Figure 1 and Table3)istheabilityofthestudentstoreflectandthevariouslevelsofreflection(reflection-on-action and reflection-in-action)56 that maycontribute to the advancement of clinicalreasoning skills. Wainwright and colleaguesdescribe the usefulness of reflection in dif-ferentiatingthethinkingprocessesofnoviceversusexpertphysicaltherapycliniciansandhowreflectionhelpedidentifythecomplexityofthisprocess.64Theavailableevidencesup-portsthefindingthatreflectionisanessentialcomponentofprofessionaldevelopmentandthedevelopmentofclinical reasoning.19,65-67

Dataindicatedparticipantsprogressedalonga continuum over time in their clinical rea-soningskills.Thisprogressiontowardprofes-sional practice may have been facilitated by

participant ability to engage in meaningfulreflection and accept responsibility for theirownperformance,as seen in the“improvedreflectiononperformance”andcomponentsof “dynamic patient interaction” themes.68

Upon reflection, a respondent stated, “Iwould do more to make the patient com-fortable and trusting of me.” In addition toreflection, the frequency and timing of self-reflection distinguished experienced fromnovice therapists.64 Wainwright et al foundthat expert practitioners utilized reflection-in-action,56 indicating they were able tochangetheirthoughtprocessandactiondur-ing the patient/therapist encounter, whilenovice practitioners relied on self-reflectionthatoccurredfollowingthepatient-therapistinteraction.64 This is consistent with the re-sultsof this study, indicatingparticipants inthe middle of the curriculum were just be-ginning to use reflection-on-action56 whileprogressing to reflection-in-action56 towardtheend.

Althoughthemajorityofparticipantspro-gressedalongtheclinicalreasoningdevelop-mental continuum, some students did notprogressasquicklyasothersandstruggledtoreachtheprofessionalperformancestandard,asdescribedintheconceptualmodel.Thesestudentsseemedtoremain focusedontheirown performance of skills and demonstrat-ed minimal evidence of significant patientawareness.Asthesestudentsmayhavestartedatalowerlevelofreasoningability,moretimefordevelopmentandadditional exposure topatientswithreflectionandguidedfeedbackcouldhelpenhancetheirlearning.Somestu-dents simply became “stuck” at a particularlevelwithouttheabilitytofurtherreflectandlearnfromtheexperience.Certainaspectsofcurriculardesign, suchasa strong focusonskill development or testing for a right an-swer,couldcontributetothisproblem.Earlyattention to psychomotor skill developmentmaydetract fromastudent’sabilitytofocuson patient-centered issues. Assessment ofstudentperformanceinthefirst2to3semes-tersoftheprograminthisstudytendstobeweighted heavily toward psychomotor skilldevelopment rather than clinical reasoning.Studentswhohavedifficultyprogressingoutofthisstagemaybenefitfromearlylearningexperiencesandassessments thathelp themconsider the larger situational context of apatient’sproblemaspartoftheirlearningex-perience.

While some students struggled with de-velopingtheirclinicalreasoningskillsasthecurriculum progressed, others exceeded ex-pectations,asevidencedbythe“outliercases.”Thesestudentsmayhavedevelopedexcellentreflectivecapabilities throughstructuredex-

periences prior to professional education ormay have been able to integrate and reflectonpatientexperiencesatacomparativelyad-vancedlevelthroughouttheprogram.

Limitations

Thestructureofthecurriculummayhaveaf-fectedtheoutcomes.Theearlypartofthecur-riculum, particularly the CCPE, focuses onproceduraloutcomes.Therefore,thestudentsmay have reflected accordingly. In addition,simple, straight-forward cases are presentedinitiallyinthecurriculumfollowedbymorecomplex cases and concepts. This may haveinfluenced the students’ abilities to considermultiple patient factors in the beginning ofthecurriculum.Acompletecohortofpartici-pantswasnotavailableinsemester8duetothestructureofthecurriculum,astheCCPEis not a required component immediatelyprior to graduation. However, although thenumberofparticipantswaslessthanprevioussemesters, the authors deliberately recruitedparticipantswitharangeofacademicabilitiestoprovideacomparablesample.

CONCLuSION Clinicalreasoningisanessentialskillforthepreparation of competent, effective physicaltherapists. Currently, we know little aboutthe development of this reasoning processin physical therapy students. Although wediscuss how important the clinical reason-ingprocessisinacademic,clinicaleducation,andclinicalresidencyprograms,welackthetools to be able to identify and assess clini-calreasoningskills.Iftheexpectationisthatstudent clinical reasoning skills will evolveand develop throughout the curriculum,learning experiences that target the devel-opment of critical self-reflection about stu-dentthinkingormetacognitiveskillsshouldbe intentionally integrated in didactic andclinical components of the educational pro-gram. In professional education, a learningenvironmentexists that isoften too focusedon certainty or student formulation of the“right answer” versus engaging the studentinseriouscriticalanalysisofhisorherownthinkingandlearningprocessfocusedonherunderstandingoftheuncertaintyofthesitu-ation. Standards and expectations for eachlevelofdevelopmentofastudentclinicalrea-soningprocesswouldbehelpful innotonlyproviding benchmarks for current expecta-tions, but would place student performanceexplicitlywithinacontinuumofcompetence.Theresultsofthisstudyprovideinsightintostudentlearningatvariousstagesofthecur-riculum. This information can guide peda-gogical and assessment strategies to betterfacilitate clinical reasoning in physical ther-


apyeducationprograms.Furtherresearchisneededtodeterminethebest tools toassessclinical reasoning skills in physical therapystudents,aswellasstrategiestofacilitatethelearning process in the didactic and clinicalportionsofthecurriculum.

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Presurvey

1) Thinking about your upcoming clinical competence performance examination (practical exam) with the selected patient case, how will personal factors including patient beliefs, perspectives, culture, attitude, socioeconomic status, and education be a part of your planned physical therapy examination and intervention?

2) Describe your thought process and initial impressions about the selected case you’ve been given for the clinical competence performance examination. What do you think the patient’s priorities from the physical therapist’s perspective could be that you would want to address?

3) What are the key physical therapy examination components (process of obtaining a history, performing a systems review, and selecting and administering tests and measures to gather data about the patient) that you want to perform? Provide specific details/examples for the exam categories of patient history, systems review, and test and measures and justify why you chose these components.

Postsurvey

1) If you were able to repeat this clinical competence performance examination experience, what would you do differently and why?

2) Based upon your interaction with the patient during the physical therapy examination and intervention piece of the clinical competence performance examination, how did you modify your plan of care or approach to this patient? Your answer may include personal factors such as patient beliefs, perspectives, culture, socioeconomic status, or education.

3)

a. List 2 tests and measures you choose to use with your patient.

b. Justify your rationale for performing these tests and measures

c. What information did you use to develop your physical therapy diagnosis or plan of care?

Appendix A. Clinical Reasoning Reflection Questionnaire (CRRQ)

Appendix B. Clinical Performance Instrument “Clinical Reasoning” Dimensions49

Applies current knowledge, theory, clinical judgment, and the patient’s values and perspective in patient management.

Sample Behaviors

a. Presents a logical rationale (cogent and concise arguments) for clinical decisions.

b. Makes clinical decisions within the context of ethical practice.

c. Utilizes information from multiple data sources to make clinical decisions (eg, patient and caregivers, health care professionals, hooked on evidence, databases, medical records).

d. Seeks disconfirming evidence in the process of making clinical decisions.

e. Recognizes when plan of care and interventions are ineffective, identifies areas needing modification, and implements changes accordingly.

f. Critically evaluates published articles relevant to physical therapy and applies them to clinical practice.

g. Demonstrates an ability to make clinical decisions in ambiguous situations or where values may be in conflict.

h. Selects interventions based on the best available evidence, clinical expertise, and patient preferences.

i. Assesses patient response to interventions using credible measures.

j. Integrates patient needs and values in making decisions in developing the plan of care.

k. Clinical decisions focus on the whole person rather than the disease.

l. Recognizes limits (learner and profession) of current knowledge, theory, and judgment in patient

Documents

Exploration of Students’ Clinical Reasoning … of Students...Reasoning Development in Professional Physical Therapy ... ical reasoning is the critical thought process ... in the