Lisa Black

Exploration of Students' Clinical Reasoning Development in Professional Physical Therapy Education

Background and Purpose. Given the complexity of the current health care environment, effective clinical reasoning skills are fundamental to making critical patient care decisions. The purpose of this study was to explore the clinical reasoning abilities of students across time in 1 professional Doctor of Physical Therapy (DPT) curriculum. Methods. Qualitative methods were used to describe the longitudinal development of students’ clinical reasoning skills. Ninety‐eight students from 2 consecutive class cohorts participated. Low inference data from the Clinical Reasoning Reflection Questionnaire (CRRQ) and narrative comments from the Clinical Performance Instrument (CPI) were analyzed using the constant comparative method. Open coding was used to initially categorize the data followed by axial coding to identify resulting themes. Results. Three categories (beginning, intermediate, and entry‐level) and 8 themes emerged from the data describing student development of clinical reasoning skills. The following themes surfaced under the beginning clinical reasoning process category: focus on self, compartmentalized thinking, and limited acceptance of responsibility. Themes in the intermediate category were: procedural performance, initial stages of recognition and using context, and improved reflection on performance. Themes in the final entry‐level category were: dynamic patient interaction and integrating situational awareness. Discussion and Conclusion. The results of this study demonstrate a progression in the development of these students’ clinical reasoning process around the dimensions of self, context, and responsibility across the curriculum. Outcomes reveal these key aspects of the clinical reasoning process: (1) it is a gradual developmental process across time; (2) the Dreyfus model of skill acquisition may apply to the development of clinical reasoning skills in physical therapy students; and (3) increasing intensity and depth of the reflective process may be a critical component in the advancement of the clinical reasoning process. Further research is needed to determine the best strategies to assess clinical reasoning abilities in physical therapy students and to discern approaches to enhance this learning process.

Effects of a Thoracic Mobility and Respiratory Exercise Program on Pulmonary Function and Functional Capacity in Older Adults

The purposes of this study were to describe a home exercise program (HEP) consisting of respiratory exercise and stretching thoracic muscles and to determine how regular participation in this program affected pulmonary function, chest wall excursion, physical function, and quality of life in community-dwelling older adults. Thirty-seven volunteers (mean age 80.5 years) participated in a twice daily HEP for 6 weeks. Twenty-two subjects completed the program. Pulmonary function, chest wall excursion (CWE), the 6-minute walk test (6MWT), the physical performance test (PPT), and RAND SF-36 quality of life survey (SF-36) were administered before and after the exercise program. Increases in CWE, 6MWT, and PPT were statistically significant. In conclusion, community-dwelling older adults participating in a 6-week stretching and respiratory exercise program demonstrated improved CWE and function.

Clinical Reasoning: Survey of Teaching Methods, Integration, and Assessment in Entry-Level Physical Therapist Academic Education

Background Although clinical reasoning abilities are important learning outcomes of physical therapist entry-level education, best practice standards have not been established to guide clinical reasoning curricular design and learning assessment. Objective This research explored how clinical reasoning is currently defined, taught, and assessed in physical therapist entry-level education programs. Design A descriptive, cross-sectional survey was administered to physical therapist program representatives. Methods An electronic 24-question survey was distributed to the directors of 207 programs accredited by the Commission on Accreditation in Physical Therapy Education. Descriptive statistical analysis and qualitative content analysis were performed. Post hoc demographic and wave analyses revealed no evidence of nonresponse bias. Results A response rate of 46.4% (n=96) was achieved. All respondents reported that their programs incorporated clinical reasoning into their curricula. Only 25% of respondents reported a common definition of clinical reasoning in their programs. Most respondents (90.6%) reported that clinical reasoning was explicit in their curricula, and 94.8% indicated that multiple methods of curricular integration were used. Instructor-designed materials were most commonly used to teach clinical reasoning (83.3%). Assessment of clinical reasoning included practical examinations (99%), clinical coursework (94.8%), written examinations (87.5%), and written assignments (83.3%). Curricular integration of clinical reasoning-related self-reflection skills was reported by 91%. Limitations A large number of incomplete surveys affected the response rate, and the program directors to whom the survey was sent may not have consulted the faculty members who were most knowledgeable about clinical reasoning in their curricula. The survey construction limited some responses and application of the results. Conclusions Although clinical reasoning was explicitly integrated into program curricula, it was not consistently defined, taught, or assessed within or between the programs surveyed-resulting in significant variability in clinical reasoning education. These findings support the need for the development of best educational practices for clinical reasoning curricula and learning assessment.

Clinical Reasoning: Development of a Grading Rubric for Student Assessment

Background and Purpose. Clinical reasoning is a complex but vital skill required for professional physical therapy practice. Experts agree that clinical reasoning is both difficult to define and challenging to assess. In order to facilitate the development of clinical reasoning skills in physical therapist (PT) students, educators need to be able to evaluate this process. The purpose of this paper is to describe the development and revision of a tool to assess PT student clinical reasoning skills across the curriculum. Method/Model Description and Evaluation. A Clinical Reasoning Grading Rubric was created using the following multistep process: (1) Initial pilot research exploring the clinical reasoning process students used in a performance‐based examination, (2) use of theoretical constructs from cognitive learning theory and learner skill acquisition, (3) content expert review, and (4) feedback from key stakeholder groups (clinicians, faculty, and students). Outcomes. The rubric was developed to assess student clinical reasoning skills across the curriculum and evaluate student readiness for the clinical setting. The tool allows faculty and students a structure to identify and track the progression of student reasoning skill development. Discussion and Conclusion. The Clinical Reasoning Grading Rubric is 1 tool that can be used to evaluate the clinical reasoning of students at multiple points in time across the curriculum. This instrument has applicability for assessment of clinical reasoning skill development from clinical to residency education. The rubric also provides insight into the teaching and learning environment and may be helpful in informing pedagogical strategies and curriculum change.

Physiotherapy Clinical Placements and Learning to Reason

Learning to reason should be experienced within a continuum of professional development, guided by curricula explicitly focused on the learning of and from clinical reasoning. We contend that this learning should be initiated during professional entry education, and intentionally built upon through post-entry-level continuing professional clinical education opportunities. While the focus and examples provided in this case are primarily from the authors’ entry-level education teaching and curriculum development experiences, we also extend our discussion to consideration of how learning to reason should and can be further facilitated within post-professional entry education contexts such as residency and fellowship programs.

Tracking Change in Critical-Thinking Skills

Background and Purpose. Critical thinking, knowledge, skill, and self‐reflection are the hallmarks of clinical reasoning in physical therapy. Teaching and measuring a highly complex entity such as clinical reasoning is a challenging task and often requires multiple pedagogies and assessments. Knowledge and skill are frequently assessed by educators, but critical thinking and skills of reflection are not. Previous studies have used standardized tests to assess clinical reasoning skills of physical therapist students. These studies report conflicting findings potentially due to the fact that neither test was designed to test critical thinking of allied health practitioners. The Health Sciences Reasoning Test (HSRT) was designed specifically for health science students with questions written in a health care context. Participants. In 2008, 63 students, 37 from a public East Coast university and 26 from a private Midwest university were recruited to complete the HSRT. Method. The students completed the HSRT at 3 points in their education: upon entry to the program, prior to final affiliations, and again just prior to graduation. Outcomes. Analysis indicated a statistically significant change for the total score as well as the deductive and analysis subscales. Post‐hoc analysis indicated these differences occurred between times 1 and 2 for the total score as well as both subscales. There was a significant difference between the 2 schools after adjusting for variance in initial test scores. The Midwest school’s mean score (24.85) was greater than the east coast school’s (22.42), and this difference was significant F1 = 12.65; P < .05. Conclusion. The HSRT was able to detect change in critical thinking scores. This finding, coupled with those of a previous study in which the HSRT was able to detect differences between experts and novices, indicate the HSRT may have validity and therefore may be a useful tool for assessing the critical thinking skills of physical therapist students.

Two Year Sustainability of the Effect of a Financial Education Program on the Health and Wellbeing of Single, Low-Income Women

Financial stress is implicated in poor health and decreased Quality of Life (QOL). The purpose of this project was to assess the 2-year effect of a financial education program on the health of single, low-income women. A total of 30 women were enrolled and 20 continued through follow-up. Two years following intervention, women demonstrated a

The Tale of Two Promising Novices

8,026 increase in mean annual income and significant improvements in health-related QOL and hopefulness. Half of the participants lost weight, and while not statistically significant, mean weight decreased by 2.2 pounds. Trends in decreased fast food consumption were observed. The results suggest that financial education has a significant, sustained effect on the health and health-related QOL of single, women of low income.

The First Year of Practice: An Investigation of the Professional Learning and Development of Promising Novice Physical Therapists

Several years ago, seven colleagues from the United States interested in the early professional development of novice physical therapists undertook a qualitative study to explore this under-investigated area of therapist learning and growth. We were building upon the work of Jensen and colleagues (1999, 2007) who had completed a landmark study of expertise in physical therapy practice in the U.S. Their work raised this intriguing question: What factors, internal or external, led some therapists toward growth into mastery yet not others? We decided to begin our search for answers by studying promising novice therapists during their first 3 years of practice. More details on the study design, methods and findings have been reported elsewhere (Black et al., 2010; Mostrom et al., 2011).