Ian Edwards

Clinical reasoning and population health: Decision making for an emerging paradigm of health care

Chronic conditions now provide the major disease and disability burden facing humanity. This development has necessitated a reorientation in the practice skills of health care professions away from hospital-based inpatient and outpatient care toward community-based management of patients with chronic conditions. Part of this reorientation toward community-based management of chronic conditions involves practitioners’ understanding and adoption of a concept of population health management based on appropriate theoretical models of health care. Drawing on recent studies of expertise in physiotherapy, this article proposes a clinical reasoning and decision-making framework to meet these challenges. The challenge of population and community-based management of chronic conditions also provides an opportunity for physiotherapists to further clarify a professional epistemology of practice that embraces the kinds of knowledge and clinical reasoning processes used in physiotherapy practice. Three case studies related to the management of chronic musculoskeletal pain in different populations are used to exemplify the range of epistemological perspectives that underpin community-based practice. They illustrate the link between conceptualizations of practice problems and knowledge sources that are used as a basis for clinical reasoning and decision making as practitioners are increasingly required to move between the clinic and the community.

Closing the Gap Between Ethics Knowledge and Practice Through Active Engagement: An Applied Model of Physical Therapy Ethics

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the “active engagement model,” is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

Moral Agency as Enacted Justice: A Clinical and Ethical Decision-Making Framework for Responding to Health Inequities and Social Injustice

This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of “justice,” which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective—the capability approach to justice—was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of “wide reflective equilibrium” and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual “crossing” and “re-crossing” of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.

Evaluating moral reasoning outcomes in physical therapy ethics education: stage, schema, phase, and type

Abstract Background: Physical therapists must have skills in moral reasoning (the ability to analyze ethical situations in order to determine a right action). The cognitive developmental perspective initiated by Kohlberg and developed by James Rest and associates proposes that moral reasoning progresses in stages or schemas (default frameworks for determining a right course of action) with periods of transition or consolidation between schemas. The purpose of this research was to evaluate changes among physical therapy students in moral reasoning and organization of ethical knowledge following an intensive 6-week ethics course focused on transformative learning, self-knowledge/reflection, relationships between ethical and clinical knowledge, and responding to ethical disequilibrium. This paper focuses on evaluating changes in moral reasoning from the cognitive developmental perspective using the Defining Issue Test (DIT2). The DIT2 evaluates the proportion of moral reasoning that an individual uses in three schemas (personal interest, maintaining norms, post-conventional) with a focus on the shift to post-conventional reasoning. Methods: A pre-test–post-test design was used to evaluate changes in moral reasoning schema. Results: Of the 54 final year physiotherapy students invited to participate, 37 students completed all portions of the research, a usable response rate of 68·5%. The resulting sample was predominantly female (59·5%, n = 22) with a mean age of 24·2 years. Paired t-tests were not significant for changes in personal interest or maintaining norms, but were significant for changes in post-conventional reasoning. Discussion: Results indicate that an intensive ethics course can be successful in producing changes in post-conventional moral reasoning among physical therapy students.

New Perspectives on the Theory of Justice: Implications for Physical Therapy Ethics and Clinical Practice

Recent revisions of physical therapy codes of ethics have included a new emphasis concerning health inequities and social injustice. This emphasis reflects the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. This perspective article suggests that there is a “disconnect” between the societal obligations and aspirations expressed in the revised codes and the individualist ethical frameworks that predominantly underpin them. Primary health care is an approach to health care arising from an understanding of the nexus between health and social disadvantage that considers the health needs of patients as expressive of the health needs of the communities of which they are members. It is proposed that re-thinking ethical frameworks expressed in codes of ethics can both inform and underpin practical strategies for working in primary health care. This perspective article provides a new focus on the ethical principle of justice: the ethical principle that arguably remains the least consensually understood and developed in the ethics literature of physical therapy. A relatively recent theory of justice known as the “capability approach to justice” is discussed, along with its potential to assist physical therapy practitioners to further develop moral agency in order to address situations of health inequity and social injustice in clinical practice.

The development of moral judgment and organization of ethical knowledge in final year physical therapy students

Abstract Background and purpose: It is well recognized that physical therapy practitioners need to go beyond adherence to professional codes of conduct and have skills of ethical reasoning in order to address the ethical issues which arise in clinical practice. There is little consensus in physical therapy regarding approaches to teaching ethical reasoning. The purpose of this research was to study changes in the moral reasoning schema and organization of ethical reasoning knowledge of final year physical therapy students following a 6 week intensive ethics course with a teaching focus on two particular ethical reasoning models: the Four Component Model and the Ethical Reasoning Bridge. Methods: A pre-test post-test design was used to evaluate changes in moral reasoning schema (using the Defining Issues Test version two (DIT2)) and changes in the organization of students’ ethical reasoning knowledge using concept maps. Results: Thirty-seven students completed all four portions of the research, a response rate of 68·5%. There was a significant increase in post-conventional reasoning (so called N2) scores (35·2 to 39·7, P = 0·006). Concept maps post-test displayed a shift from a pre-test quantitatively oriented and organised set of ethical knowledge concepts to a more integrated and qualitatively oriented new knowledge framework. Conclusion: This study has demonstrated that a 6 week course using curricular strategies involving the interpretation of experience and perspective transformation can facilitate in a cohort of final year physical therapy students both the development of ethical reasoning ability (moral judgment) and a richer organization of the types of knowledge required for ethical decision making.

A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care

BackgroundMany patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study.MethodsThe qualitative methodology applied was a constructivist grounded theory approach.Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled.Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes.ResultsOur analysis highlighted ‘predicted discharge destination’ as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient’s pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress.ConclusionsOur qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients.

Measuring the quality of dysphagia management practices following stroke: a systematic review

Adherence to recommended clinical practices improves stroke outcomes. As a result, stroke clinicians are increasingly expected to evaluate the quality of the care they provide so that areas for improvement can be targeted. Finding the best method to evaluate the quality of dysphagia management can be challenging. Aim To systematically review process indicators used to assess the quality of care provided to patients with dysphagia following acute stroke and examine the level of evidence underpinning these indicators. Methods Databases were systematically searched to identify publications (January 2006–April 2009) that describe process indicators relating to the clinical management of acute stroke-related dysphagia. Relevant process indicators were extracted from the reviewed publications for detailed post hoc analysis including supporting evidence and alignment to the current Australian and English stroke guidelines. Results Title and abstract review found 150 potential studies. Full-text review resulted in 25 publications that met the studys inclusion criteria. Thirteen process indicators were identified in the literature that related to the initial assessment, clinical management, rehabilitation and discharge planning for patients with acute stroke-related dysphagia. These processes were supported by levels of evidence ranging from high ‘level 1’ (8%) down to ‘expert opinion’ evidence (46%). Two process indicators did not align to recommendations in the clinical guidelines. This systematic review underpins informed selection of process indicators for evaluating the quality of dysphagia management following stroke. The selection of quality indicators is complicated by equivocal supporting evidence; however, indicators should reflect expected local practices, align with national stroke guidelines and be feasible for clinical auditing.

Cognitive maps and the structure of observed learning outcome assessment of physiotherapy students’ ethical reasoning knowledge

Assessment of student learning in complex areas is challenging, particularly when there is interest in students’ deeper understanding and connectivity of concepts. Assessment of ethics learning has been limited by lack of consensus regarding what is effective and an overfocus on quantification at the expense of clinical or ethical relevance. Cognitive maps provide one means to evaluate depth and personal meaning of students’ ethics knowledge. A pre-/post-test design using cognitive maps and the structure of observed learning outcome (SOLO) taxonomy was used to assess student learning on completion of a six-week intensive ethics course. Thirty-seven students completed the research. Student learning was supported by significant changes in component (content, labelling, relationships and structure/visual message), and total pre- and post-test cognitive map scores, and significant change in pre- and post-test SOLO scores. A strong relationship was found between cognitive map improvement and SOLO improvement. Student written commentaries describing their post-test cognitive map provided a richer, more elaborated account of their understanding that qualitatively enhanced their cognitive maps. Cognitive maps offer an alternative to traditional ethics assessment strategies.

Living a moral professional life amidst uncertainty: Ethics for an Afghan physical therapy curriculum

Abstract This paper is the outcome of an ongoing dialogue about professional ethics between expatriate (and Western) physical therapy teachers and Afghan physical therapy teachers and colleagues. There is a current need to teach ethics in an Afghan physical therapy curriculum. However, the process by which the content for this would be developed stands in contrast to the “usual processes” of expatriate physical therapy teachers or consultants assisting in the development and teaching of curricular material, which, in turn, has steadily been moving towards an evidence-based practice model. The development of an ethics curriculum for Afghan physical therapists raises pedagogical and cultural issues for both expatriate and local educators. This dialogue about ethics for professional practice in Afghanistan identifies two ethical tensions: between normative ethical theory (with its universal truths and values, expressed in codes of conduct) with so-called “local moral experience” (Kleinman, What really matters: living a moral life amidst uncertainty and danger; Oxford University Press, 2006); and between individualistic and communitarian understandings of ethics. We propose a narratively oriented ethical approach to resolve these tensions in ethical action, which has pedagogical and professional practice implications across national and cultural boundaries.