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IntroductionIntroduction

• We are entering a period in which the occupational therapy curriculum worldwide is undergoing dramatic transformation and experiencing significant structural changes.

• The role of curriculum design is one of the focal issues in this transformation and clinical reasoning is the core of occupational therapy practice. With evolving theories, rapidly developing technology, and expanding practice areas, occupational therapy educators have been challenged to determine the necessary course content to prepare students for entry-level practice and as a consequence different models of fieldwork are presently being proposed.

Aims of this StudyAims of this Study

• The study examined implications for curriculum design resulting from a two-year longitudinal study of a cohort of 80 Occupational therapy students, which explored their development of learning from novice to beginning therapist using a range of measures and

• Show what evidence is there for the progressive development of clinical reasoning skills in trainee occupational therapy students of the Hong Kong Polytechnic University?

Methodology & Design of StudyMethodology & Design of Study

Research DesignResearch Design

• This study adopted a mixed method study design (Longitudinal), which followed over two years and performed repeated measurements at different stages of their clinical reasoning development.

Sample PopulationSample Population

• The student cohort of the study composed of a class of 80 Hong Kong OT students enrolled into the study at the end of their first year of the three-year BSc (Hons) Degree in Occupational Therapy programme.

Methodology & Design of StudyMethodology & Design of Study

• Test Instrument used:Test Instrument used:

• The Self-Assessment of Clinical Reflection and Reasoning (SACRR): Consists of two sections:

– The first section contains demographic information.

– The second section contains 26 close-ended questions that evaluate different aspects of clinical reflection and reasoning.

– These questions use a 5-point Likert scale from “strongly agree”(5) to “strongly disagree” (1).

• Reliability of SACRR: – Cronbach’s alpha for pre-test was 0.87 and for the post-test

was 0.92 suggesting a high internal consistency.

Organisation of Academic & Clinical Education - BSc (Hons) in Occupational Therapy

Integration between Academic Integration between Academic subjects and Clinical Education subjects and Clinical Education

SubjectsSubjectsClinical Education I (CE I):– CE IA (2 weeks) takes place at the beginning of Year I

summer vacation whilst Clinical Education IB (3 weeks) takes place after the first semester of Year 2.

– CE I provides students with the opportunity to identify functional problems encountered by people with disabilities, and the roles and functions of an occupational therapist, as well as observe the occupational therapy intervention process within various clinical settings.

Clinical Education II (CE II): – CEII takes place during Year II summer term. This 8-week

clinical placement provides students with the opportunity to participate as contributing members of a multidisciplinary/rehabilitation team and to enhance their experience in adopting a holistic approach to client care.

Integration between Academic Integration between Academic subjects and Clinical Education subjects and Clinical Education

SubjectsSubjectsClinical Education III (CE III) & Clinical Education IV (CE IV):

– CE III & CE IV takes place in the middle of first semester (8 weeks) and the beginning of second semester (8 weeks) of final year respectively.

– These two subjects provide students with the opportunity to consolidate, integrate, and apply knowledge, skills and attitudes learned at the University to occupational therapy practice.

– Students are expected to take responsibilities to seek guidance, to update their knowledge and skills, as well as to evaluate their own practice independently.

Factor loading of the 26 items of Self-Assessment of Clinical Reflection and Reasoning (SACRR) after maximum likelihood varimax rotation

Factor Loadings

Items Factor

1 Factor

2 Factor

3 Factor

4 CEIV10 0.81 0.02 0.26 -0.02 CEIV8 0.74 0.19 0.09 -0.17 CEIV7 0.72 0.02 0.13 0.20 CEIV9 0.70 0.02 0.19 -0.12

CEIV26 0.69 0.30 0.08 0.25

CEIV3 -0.11 0.66 0.02 0.11 CEIV25 0.11 0.65 -0.03 0.07 CEIV1 0.35 0.62 0.00 0.17 CEIV4 0.13 0.59 0.31 -0.09 CEIV5 -0.09 0.54 0.37 -0.11

CEIV2 0.50 0.50 -0.20 0.07 CEIV20 0.23 0.46 -0.10 -0.23 CEIV18 0.31 0.37 0.10 -0.08

CEIV24 0.33 0.34 0.03 0.15

CEIV11 0.14 0.33 0.26 0.28 CEIV16 0.30 0.19 0.76 -0.10 CEIV15 0.28 0.19 0.73 -0.10 CEIV14 0.19 0.14 0.63 -0.03

CEIV6 0.13 -0.12 0.50 0.08

CEIV13 -0.25 0.33 0.48 0.10 CEIV19 0.03 0.22 0.44 0.17

CEIV22 0.12 0.31 0.43 0.27 CEIV17 0.10 0.07 0.14 -0.77

CEIV21 0.20 0.11 0.44 0.54 CEIV23 0.08 0.03 0.44 0.49

CEIV12 0.31 0.35 0.22 0.39

ResultsResults

Results of factor analysis and thematic analysis showing groupings and internal consistency coefficients Proposed Themes/Concepts

Factor Groupings

Question no. Cronbach’s

alpha

Knowledge/Theory application 1 7, 8, 9, 10, 26 0.83

Decision making based on experience and evidence

2 1, 2, 3, 4, 5, 11,18, 20, 24,

25 0.75

Dealing with uncertainty 3 6, 13, 14, 15, 16, 19, 22 0.74

Self-reflection and reasoning 4 12, 17, 21, 23 0.52

ResultsResults

Mean subscale scores for SACRR

3.30

3.40

3.50

3.60

3.70

3.80

3.90

CEII (pre) CEII (post) CEIII (post) CEIV (post)

Knowledge

Decision making

Uncertainty

Self-reflection

Total score

ResultsResults

Results (Summary)Results (Summary)

• Mean of total scores increased gradually over 4 periods (CEII to CEIV) of clinical education placements indicating that the gradual change over time in both dimension of students’ reasoning and reflection which is presumed to be due to exposure to different learning experiences in a variety of clinical settings.

• The overall change in students’ development of contextual learning of specific reasoning occurred at the end of year 2 (CEII-post-test) and not at the beginning of year 2 (CEII-pre-test). This finding is important as it suggests that it is reflection, or the processing of experiences and the search for meaning within them, which promotes learning (Boud & Walker, 1991; Schön, 1987).

DiscussionDiscussion

Knowledge/Theory Application:Knowledge/Theory Application:

– Students during focus group interview rated “integration of theory to practice” as one of the four most important things that they learned in their clinical education placements. Based on this evidence, it is seen that clinical reasoning has become yet another “skill” to be taught among other skills and that it has been interpreted as having a reason for connecting a particular treatment decision to a particular frame of reference or a theory.

DiscussionDiscussionDecision making based on experience and evidence:

– The results of mean scores in this Grouping clearly indicated a greater change in students’ clinical decision-making skills after CEII (post) placement, which took place at the end of their second year of study.

– This is a significant curricular implication, which clearly recognises the fact that subjects in Year 1 appeared to be not directly contributing to patient treatment and unresolved clinical problems but also acknowledge that Year 1 is mainly a foundation year in which students expected to learn theoretical knowledge from Biological, Behavioural and OT Theory and Process subjects.

DiscussionDiscussion

Dealing with uncertainty:

– The findings confirmed that exposure to the uncertainty of an unstructured methodology might foster more active participation by the students in clinical education placements and thus facilitate the transition from one mode or level of critical thinking to a higher order for better planning of clinical interventions.

– Based on this study, it is important to point out that most occupational therapy curricula teach students only the most popular theories, how to apply them to straightforward cases and fails to equip students with the skills that they need to deal with the unstructured methodology and ill-defined problems.

DiscussionDiscussion

• Self-reflection and reasoning:

– During supervision and integration with students, clinical educators begin to explicit explanations of their reasoning process. This kind of interchange can facilitate communication and self-reflection by both therapist and student. This view is clearly substantiated in this research; when students asked “what you think you are better at as a result of the course?”

Conclusions and RecommendationsConclusions and Recommendations

• This study offers the resolution of one of the most crucial and baffling problem encountered in the field of clinical reasoning, namely the extent to which clinical reasoning can be articulated and explained to beginning practitioners in their undergraduate curriculum.

• The findings also point out the need to identify and understand that a `new’ epistemology fundamentally characterizes professional practice as judgment and wise action in complex, unique, and uncertain situations with conflicting values and ethical stances in a social and cultural context.

Conclusions and Conclusions and RecommendationsRecommendations

• Many other valuable considerations such as the teaching of different modes of reasoning, the learning of patterns and processes of reasoning both to give meaning to clinical decisions and to explain action, and the teaching of appropriate techniques for accessing encrypted knowledge fall within the ambit of a thinking curriculum.

• Clinical reasoning as an area of advanced specialism, it is now in the forefront of professional practice. As such it needs to be accorded a special place in the undergraduate curriculum. Similarly, because of the cognitive complexity inherent in the clinical reasoning it seems evident that this area of practice provides an advanced knowledge-base for the teaching and learning of clinical reasoning skills in preparation for complex practice.

Conclusions and Conclusions and RecommendationsRecommendations

• A high percentage of what has been researched concerns with models of clinical reasoning rather than clinical practice. This study has only been able to report on one area of interest in the development of clinical reasoning skills as a novice-expert continuum in the undergraduate curriculum but it also had the effect of drawing attention to the need for further research into many facets of the client-therapist relationship.

AcknowledgementsAcknowledgementsMy sincere gratitude goes to the following people without their support, this study would not have been possible:

– Former students and staff of the Department of Rehabilitation Sciences at the Hong Kong Polytechnic University, particularly Dr Kit Sinclair for constructive comments and Mr. Peggo Lam for statistical advice.

– Mr Kevin Durkin, IT Technical Assistant, School of Health Professions and Rehabilitation Sciences at the University of Southampton for multi-media support and design contribution.

Thank you.Thank you.