Susan Wainwright

Factors That Influence the Clinical Decision Making of Novice and Experienced Physical Therapists

Background The depth and breadth of prior experience informs clinical decision making in novice and experienced physical therapist clinicians. Objectives The aims of this research were to identify differences in clinical decision-making abilities and processes between novice and experienced physical therapist clinicians and to develop a model of the factors that influence clinical decision making. Design Qualitative research methods and grounded theory were used to gain insight into the factors and experiences that inform clinical decision making. Methods Three participant pairs (each pair consisted of 1 novice physical therapist and 1 experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries from each participant provided the basis for within- and across-case analyses. The credibility of the results was established through checking of the case summaries by the participants, presentation of low-inference data, and triangulation across multiple data sources and within and across participant groups. Results The factors that influenced clinical decision making were categorized as informative or directive. Novice participants relied more on informative factors, whereas experienced participants were more likely to rely on directive factors. An intermediate effect beyond novice practice was observed. Conclusions The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities for students and novice learners with the aim of facilitating the development of skills and abilities consistent with expert clinical decision making.

Novice and Experienced Physical Therapist Clinicians: A Comparison of How Reflection Is Used to Inform the Clinical Decision-Making Process

Background Prior experience informs clinical decision making and shapes how reflection is used by novice and experienced physical therapist clinicians. Objectives The aims of this research were: (1) to determine the types and extent of reflection that informs the clinical decision-making process and (2) to compare the use of reflection to direct and assess clinical decisions made by novice and experienced physical therapists. Design Qualitative research methods using grounded theory were used to gain insight into how physical therapists use reflection to inform clinical decision making. Methods Three participant pairs (each pair consisting of one novice and one experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries of each participant provided the basis for within- and across-case analysis. Credibility of these results was established through member check of the case summaries, presentation of low-inference data, and triangulation across multiple data sources and within and across the participant groups. Results Although all participants engaged in reflection-on-action, the experienced participants did so with greater frequency. The experienced participants were distinguished by their use of reflection-in-action and self-assessment during therapist-patient interactions. An intermediate effect beyond novice practice was observed. Conclusions The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities to facilitate clinical decision-making abilities and the development of the skills necessary for reflection in students and novice practitioners.

Use of a Delphi panel to establish consensus for recommended uses of selected balance assessment approaches.

The Delphi survey is a useful mechanism to make recommendations for clinical judgments in the absence of practice guidelines for evidence-based decision making. Although there is a great deal of literature about the topic of various methods of balance assessment, decisions about application of research evidence for clinical practice may be subject to personal interpretation and/or biases of the reader. In this study, a panel of informed experts was used through a Delphi process to establish consensus regarding the recommended use of selected balance assessment methods based on the literature. Selective recruitment of experienced faculty members with advanced degrees and/or specialist certification in the content area identified seven knowledgeable informants. The panel participated in three rounds of discussion to develop a consensus-based summary of the recommended use of balance assessment methods commonly used in clinical practice and suggest how those measures fit within the framework of the Patient/Client Management Model of physical therapy practice. The outcomes of the Delphi process form a basis for recommended practice in the examination of patients with balance deficits and serve as a starting point in the development of evidence-based practice guidelines.

Cycling With Functional Electrical Stimulation in an Adult With Spastic Diplegic Cerebral Palsy

Background and Purpose Adults with cerebral palsy (CP) are at risk for decreased mobility and health complications, and exercise may combat some of these negative changes. Because people with CP have difficulty generating sufficient muscle force, exercise augmented with functional electrical stimulation (FES) is an option for increasing exercise intensity. This mixed-method (quantitative-qualitative) case report describes the effects—across the International Classification of Functioning, Disability and Health (ICF) model—of cycling with FES (FES cycling) in an adult with CP. Case Description An ambulatory 49-year-old man with spastic diplegic CP cycled with FES at home for 30 minutes, 3 times per week, for 12 weeks. Volitional efforts were augmented by FES of the bilateral quadriceps, gastrocnemius, and gluteal muscles. Testing was performed before and after the intervention and 4 weeks after intervention withdrawal. Outcomes After training, quadriceps muscle strength (force-generating capacity) improved by 22.2%, hamstring muscle strength improved by 18.5%, and the Timed “Up & Go” Test time decreased from 11.9 to 9.0 seconds. The patient reported increased performance and satisfaction for self-identified goals at the ICF level of participation, and his score on the Medical Outcomes Study 36-Item Health Survey questionnaire increased from 62.1 to 77.6. However, he reported increased back pain, which he attributed to positioning while cycling. Qualitative interviews provided context (the patients perspective) for some of the quantitative results. Discussion The patient made gains in body structure and function, activity, and participation (ICF levels) after FES cycling. The mixed-method approach provided insight into his experiences and perceptions about the measures assessed quantitatively. Further investigation on FES cycling in this population as well as positioning during cycling is warranted.

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.

A Comparison of 2 Case Delivery Methods: Virtual and Live

Background and Purpose. Time, safety issues, and patient availability often limit the amount of hours that professional physical therapist students are able to spend in the clinical setting. Therefore, there is a need to develop educational approaches that afford students the opportunity to engage in meaningful practice with realistic patient scenarios in order to develop clinical‐reasoning skills. The authors propose virtual patient experiences delivered through technology. Methods. A sequential, mixed‐methods design was used to study 2 methods of delivery (large group discussion [LGD] and virtual patient simulation [VP]) on clinical reasoning, knowledge acquisition, transfer of knowledge, and students’ perception of their learning. Students were randomly assigned to either LGD or VP groups to complete 6 patient cases related to course material. Results. There were no significant differences between groups for clinical reasoning as measured by the Health Science Reasoning Test (HSRT); however, there were within‐group differences for the simulation group only. Additionally, qualitative data revealed differences between groups in clinical reasoning and level of engagement. Discussion and Conclusion. There were no significant differences between the 2 delivery methods; however, the simulation group did score higher on all objective measures. The VP offers students the benefit of working independently and reduces faculty group facilitation time. Thus, virtual patient experiences holds promise as a tool to teach clinical reasoning as well as knowledge acquisition and transfer of knowledge skills.