A qualitative study of clinical reasoning in physiotherapy: Perceptions of postgraduate student physiotherapists in the UK
Chapter One: Introduction
Clinical reasoning can be defined as the thinking and decision-making process applied by the clinical practitioners in making critical decisions. Higgs and Jones (2000, p.3) defines clinical reasoning as a process whereby “the therapist, interacting with the patient and others, including the family members or others providing care, helps patients structure meaning, goals and health management strategies based on clinical data, patient choices, and professional judgement and knowledge.
or any similar topic only for you
” Edwards and Richardson (2008) on the other hand, defines clinical reasoning in the context of a process that incorporates the elements of cognition, knowledge and meta-cognition, which expands to place a greater emphasis on patient-centred care.
The subject of clinical reasoning has received enormous attention from clinical practitioners and researchers alike largely due to dynamic skills expected of physiotherapists, and its development as a profession in the ever-changing health care sector. The changes can, partly, be attributed to the increasing need for independence and responsibility in decision-making. In addition, clinical reasoning is continuously becoming an important subject because it is considered part and parcel of physiotherapy as an autonomous professional field (Higgs and Hunt, 1999, p. 14). It is thus important to views clinical reasoning as an integral part of physiotherapy as a profession, because physiotherapists are obliged to make a wide variety of decisions in their daily clinical practice. In essence, every clinician has realised the need to improve their decision-making skills, which is an integral part of a clinical reasoning process.
1.2 Clinical Reasoning and the Concept of Perception
Clinical reasoning has further become more complex when the concept of perception is integrated within it. Clinical practitioners are accountable for their decisions and the services they provide. They are also answerable to stakeholders, including parents, policy makers and colleagues (Tan et al. 2010, p. 352). Patients do have the rights to understand everything they undergo, as well as the need to be heard in an open and honest conversation, and to be fully informed of all the aspects of assessment and treatment. According to Tan et al. (2010, p. 355) perception determines whether a patients and significant others will feel substantive procedures was followed in the process of delivering health and care services.
This further brings out the concept of efficient communication in the field of physiotherapy. As a physiotherapist, it is important to establish relationships with the patient, carrying out a systematic assessment of their condition (Shaw and DeForge 2012, p. 421). Psychotherapists need to be capable of clarifying clearly and realistically the scientific and clinical reasoning for their actions and the expected results, within the framework of the individual patient’s requirements, wishes and condition (Bleakley et al. 2003, p. 536). Furthermore, clinical reasoning is essential in order to make it easier for the therapist to collaborate with others in order to set proper goals and management decisions. This in turn is expected to improve patient fulfilment and obedience with therapy. Greater insights into therapist-patient relationships, distinctively clinical reasoning, are obligatory to improve efficiency in clinical practice (Bolander et al. 2006, p. 42). Communication in clinical reasoning is also crucial in establishing proper relationships with patients and nurses, for decision-making among multidisciplinary work members, and for learning purposes. Physiotherapists may be considered upon, as tutors or clinical educators, to correspond their clinical reasoning to undergraduate and trainee physiotherapists (Tan et al. 2010, p.360).
Furthermore, clinical reasoning focuses on the idea of bringing awareness to the cognitive processes that take place daily in clinical physiotherapist practice. The change from trainee to experienced therapists relies on numerous factors, in particular a development in clinical reasoning skills. A strong understanding of skilled clinical reasoning and the procedure of learning is dependent on the capabilities of physiotherapist communication (Bolander et al. 2006, p. 47).
1.3 Necessity of Clinical Reasoning for Student Physiotherapists
Various theories have intimated that patterns of clinical reasoning differ remarkably between expert clinicians and students or novice clinicians (Jones and Rivett, 2004). Clinical practitioners believe that pattern recognition is possible only with a properly organised knowledge and enormous clinical experience. This means that inexperienced students clinicians hardly use pattern recognition in their clinical practice. The general hypothesis is that novice clinicians, including student physiotherapists just use hypothesis testing clinical reasoning model more frequently (May et al., 2010).
Evidence on the dissimilarity on how experts and students physiotherapists practice clinical reasoning has been demonstrated. While expert physiotherapists have been shown to make use of pattern recognition, hypothetico-deductive and narrative reasoning, student physiotherapists solely relied on hypothetico-deductive reasoning. Moreover, student physiotherapists were not always able to conduct evaluation of any hypothesis, in addition to the revelation that their clinical reasoning process and outcome contained some errors. It has also been found that student therapists spend more time conducting physical examination, while spend the least time on taking history of patients. Experts tend to rate highly items from a patient’s history, and considers them greatly significant to the diagnostic reasoning process. More importantly, experts tend to treat history of the patient to indispensable towards implementing a successful patient-centred care, collaboration on management and encouragement of patient empowerment. Expert physiotherapists were also found to have more information and explanation when taking history during inter-reaction sessions with patients. They also built their questions based on the responses from the patients, and had more social engagement with the patients, with better communication skills than the inexperienced therapists.
The need to acquire and master practical skills in clinical practice is important for physiotherapy students’ abilities to assess and treat patients with physiological disorders. Clinical reasoning, as a thinking and decision-making process in the clinical practice, is essential for effective, proficient clinical practice and specialised autonomy of practice. Health professionals, including student physiotherapists, are responsible for their decisions and facility terms to various stakeholders, including patients, nurses, health department managers, decision-makers and work colleagues. An important feature of clinical reasoning is the ability of the professional to articulate and defend evidence-based management decisions in a way suitable to the audience (Smith et al. 2008, p.210). Clinical reasoning has emerged as an important subject of study, gaining prominence partly due to the skills required for physiotherapists and the changing nature of the profession that needs increased accountability in decision-making, which forms part of the processes that provide desirable treatment outcome (Higgs and Jones, 2000, p.7). Another important reason for the rising significance of clinical reasoning is based on the modern nature of decision making, which is based on independence and responsibility and regarded as one of the main characteristics of an autonomous profession (Higgs and Hunt, 1999; Ritchie, 1998). Clinical reasoning is challenging due to its swiftness, complexity and often hidden nature. As a result, revealing some of the practical facts that update the communication of clinical reasoning is important for psychotherapy practice, improvement and learning (Bleakley 2005, p.536). Patients have the civil rights to open frank and helpful communication and to be fully up to date regarding all features of assessment and actions (Tan et al. 2010, p. 355).
This knowledge possibly can be used in clinical situations in order to teach student and trainee physiotherapists. Additionally, health professionals are capable of developing their own knowledge of the clinical reasoning process, how to correspond to their reasoning and, significantly, how to analyse their own clinical practice (Dunphy and Williamson 2004, p. 109).
1.4 The Study Rationale
Post graduate students physiotherapists, just like experienced experts, go through the same process when gathering patients’ information during interviews. This information is expected to inform a structured physical examination process, and hopefully lead to a diagnosis classification, which finally used to inform management decisions. In spite of this knowledge, most studies have placed little focus, or none at all, on what physiotherapy post graduate students thinks about their stated insufficient skills in clinical reasoning, and what they view should be the standard strategies to help them improve their clinical reasoning skills. The field of physiotherapy has also not established modes of learning that can assist the attainment of critical listening skills among physiotherapy students, often relying solely on the subject as practiced in the general sector of health.
The objective of this research is to understand the contribution of clinical reasoning in physiotherapists’ practice and to explore the perceptions of UK physiotherapist postgraduate students. Although discipline-specific knowledge is important to clinical reasoning, it is expected that there some broad skills of communication and understanding that impact on the implementation of clinical reasoning as a practice in the physiotherapy practice. This research, therefore, aims to:
i.) Improve clinical reasoning of post graduate students by outlining underlying areas of improvements
ii.) Establish modalities to improve physiotherapy practice among post graduate students physiotherapists
iii.)Contribute to the general literature of clinical reasoning in the field of physiotherapy, and healthcare practice
in general, through establishment of structures for new learning models
Chapter Two: Literature Review
2.1 Understanding Clinical Reasoning
Earlier studies into the subfield of clinical reasoning in the field of medical practice has been largely focused on the clinical skills of physicians and medical students in relation to observable behaviours associated with general skills, as well as measurable through psychometric testing (Parry, 2004). However, this approach put emphasis on behavioural more than the process, thus heralding a period of research that was characterised by the precognitive era as well as process oriented perspective (Parry, 2004). This paradigm also led to the development of one of the research tools known as the simulation method, which subsequently aided the Rimoldi’s tests of diagnostic skills developed between 1950s and 1960s (Rimoldi 1988, cited in MacDougall and Drummond, 2005, p.1214). It is noted that in these tests, preliminary information related to a clinical case were given to subjects, together with instructions to pursue their examination by seeking additional information which was later to be provided by cue cards. When analysis of the frequency was conducted within the order of questions, the researcher was able to outline the differences between the performance of physicians and medical students. The researcher found out that physicians’ questions were fewer, appropriate and more focused than the students’ questions. In other words, practical experience increases expertise, which leads to more focus in questions and answers (MacDougall and Drummond, 2005, p.1218). So one might ask: what makes clinical reasoning so complex that only experienced clinical practitioners (or physiotherapists) to have better understanding and practice it as required?
There are key features to critical reasoning that make up its definition (Higgs and Jones, 2000, p.11), and could be considered as relevant to this research. First, clinical reasoning is a combination of both process and outcome, and more importantly, interactive in nature. Second, choices of the patients are central to the process of decision making. Last, the broad outcome is part of the reasoning process and is directly related to meaning constructions, negotiation of goals and management of decisions. It is prudent to note that these features highlight the key role of communication the critical reasoning process and the need to communicate reasoning with patients, as well as caregivers, in the general practice of physiotherapy.
Higgs and Ajjawi (2006) break down key characteristics of clinical reasoning. Some of the characteristic that are pertinent to this research are highlighted here, as follows:
– Clinical reasoning is largely invisible process, and is usually automatic thus not readily accessible to people in clinical practice and research (Higgs and Ajjawi, 2006). It is important to note that one of the goals of this research is to make clinical reasoning more explicit to the general study and practice. Making clinical reasoning explicit is one way of making it open to scrutiny, critique and investigative endeavours.
– Clinical reasoning is associated with more visible behaviours such as practitioner’s recording of diagnoses, developing and implementation of treatment plans taking patient’s history into consideration and communicating treatment rationale to teams, patients, caregivers and management. The main focus of this research is to investigate how clinical reasoning can be learned among the student physiotherapists.
– Clinical reasoning can be taken to mean both cognitive and collaborative processes; however, there is a growing imperative in either case that is tied to the rising demands for evidence-based practice, as well as, public accountability that aims to make reasoning more explicit (Higgs and Ajjawi, 2006).
– Clinical reasoning is a reflective process, which requires practitioners to develop critical self-reflection and ongoing development of their reasoning skills and abilities. As earlier, student physiotherapists or novice practitioners still lack this self-reflection and general reasoning ability when it comes to clinical reasoning.
2.2 Models of Clinical Reasoning
Clinical reasoning as a subject of study has not received any single accepted theoretical or research-based model that can single-handedly address clinical reasoning practice. Due to the complex nature and particularity of clinical reasoning, it is least surprising that there are numerous models that are used concurrently in attempts to understand and explain how it is practiced in the professional field.
Various models of clinical reasoning have been developed, and are largely based on the interactions between clinician and patient. The models, which are considered as relevant to physiotherapy, include: pattern recognition, hypothetico-deductive reasoning, and integrated model. To understand these models and how they are relevant to this study, a brief review is outlined below.
2.2.1Hypothetico-duductive Reasoning model
Hypothetico-deductive reasoning model in clinical reasoning emanated from the field of medical research, which came as a result of information-processing approach (Norman 2005, p. 420). This theory was basically developed and researched to improve accuracy of diagnosis among physicians. This model of reasoning relies on information from the patient as gathered and used to undertake hypothesis; which is subsequently tested out. Because the hypothesis should be confirmed by how patients respond to treatment, it involves repeated assessment.
Elstein and colleagues, who developed this theory in 1978, had put forward a model of medical inquiry that consisted of cue acquisition, hypothesis generation, interpretation of cue, and evaluation of the hypothesis (Norman 2005, p. 421). This original basic reasoning process advanced by the hypothetico-deductive theory was focused mainly on medical diagnosis, which also included generating and testing of competing hypothesis. One of the weaknesses of this theory is that it only used retrospective protocol that has a tendency for subjects not to give accurate account of what they actually did or thought at the time of diagnosis process. Instead, the subjects would only give a reconstructed conception of how the problem should have been solved, possibly influenced by their end-point knowledge (Parry, 2004). Although researcher’s aim in establishing this model was noble, and motivated by the need to implement systematic method to teach students, issues such as efficacy and cost-containment emerged and became even more prominent during implementation.Hypthetico-deductive reasoning in physiotherapy
Clinical reasoning origin can be linked to the work of medical problem solving research. The process of identification of hypthetico-deductive reasoning as a model of problem solving was originally found in musculoskeletal physiotherapy. In an earlier physiotherapy study that replicated Elstein and associates, physician assessment of simulated patients was followed by a methodology of video stimulated retrospective recall (Payton, 1985. Payton investigated ten physiotherapists who were involved in assessment of real patients. He identified the how the physiotherapists applied all the four stages of the hypothetico-deductive reasoning process. His conclusion was that similar clinical reasoning was used by physicians and musculoskeletal physiotherapists (Payton, 1985).
The perception that hypothetico-deductive reasoning existed in physiotherapy was further backed by another study. Rivett and Higgs (1997) conducted a study, utilising observation of a video recorded in a prior case in a problem solving study. In the study, both expert and novice physiotherapists, who helped generate hypotheses during problem solving session, were used. It consequently provided further evidence that hypothetico-deductive reasoning model was utilised in physiotherapy practice.
Hypothetico-deductive reasoning has been incorporated in many studies at the undergraduate and postgraduate programmes to act as the structural base for clinical reasoning. Although this model cannot exhaustively explain all problem solving practices, which is very critical in critical reasoning in physiotherapy, its inclusion in teaching motivated analytical thought processes that is found in physiotherapy clinical reasoning. This instigated the inclusion of a profession specific model based on hypothetico-deductive model, with the general understanding that it would be utilised within the diagnostic reasoning, particularly among the novice practitioners (Jones, et al., 2000), including postgraduate students.
2.2.2 Pattern Recognition Model
Pattern recognition is another clinical reasoning model that is mainly based on pattern recognition in clinical presentations. In the pattern recognition model, a similar case is usually used to decide whether a process should be undertaken or not. For instance, if a physician is handling a patient with a similar presentation to patients successfully treated previously, the management uses similar strategy to treat the present case. Just like Hypothetico-deductive reasoning, pattern recognition is a diagnostic strategy that can be used at any time deemed appropriate at stages of problem solving. Consequently, it is linked to the inductive and forwards reasoning, which can be defined as the movement from cues to hypothesis. Fig. 1.0 illustrates certain range of cues as practiced in a physiotherapy assessment.
Figure 1.0 Available cues for developing hypotheses using pattern recognition
Pattern recognition in physiotherapy
Various qualitative studies have been conducted in physiotherapy that identified pattern recognition as an important aspect of critical reasoning (Doody and McAteer, 2002; King abd Bithell, 1998; Noll et al., 2001). However, there have given varied definition of pattern recognition that has created discord within the findings of these studies. In Doody and McAteer (2000), pattern reasoning is based on the hypothesis generation, evaluation and bypassing of the appraisal of data relative to the hypothesis. Noll et al (2002), on the other hand, reported that pattern reasoning is based on a qualitative code, labelled as a pattern of data that is identifiable from prior experience and applied in the development of working hypothesis. King and Bitchell (1998) applied only the reported previous clinical experience similar to the present situation, and used it during retrospective interview, as an important identification of pattern recognition. It is critical to note that these studies give some insight about pattern recognition as a model for clinical reasoning, however, the evidence supporting pattern reasoning as a diagnostic strategy in physiotherapy has a clear lack of strength.
The synthesis of patter recognition model in the literature gives a wide range of characteristics. These characteristics provide insight into the understanding of the model, with characteristics based on knowledge, categorisation, efficiency and accuracy. These characteristics underpin pattern recognition and provide potential benefits within physiotherapy research.
Knowledge is considered a critical aspect of pattern recognition. That is, the ability to recognise a unique clinical patter is dependent on individual knowledge, hence a highly organised knowledge structure is argued as a basis for pattern recognition (Edwards, et al., 2004). Another approach is the categorisation, which has been utilised when dissecting pattern recognition. Some authors have advocated for wider use of categorisation, which simply refers to the grouping of objects or events, as a channel for understanding pattern recognition (Hayes and Adams, 2000).
Diagnosis reasoning strategy of pattern recognition is popularly used in the medical and physiotherapy. In spite of the many inconsistencies relating to how it’s interpreted, pattern recognition is commonly viewed as a forwards reasoning process model. In addition, despite its simplistic nature, understanding of pattern recognition can lead to efficient and accurate outcomes. ………states that consideration of pattern recognition requires proper understanding of what pattern entails, which initiates consideration of the knowledge brought about by literature. Because integration of forwards and backwards models within diagnostic reasoning is critical in the understanding of clinical reasoning process, it is significant in the investigation of postgraduate physiotherapy students.
2.2.3 The integrated Client-centred Model: A Shift in Paradigm
Previous models of clinical reasoning were criticised, especially because they lacked client involvement, and to some extent, oversimplified factors involved in the reasoning process (Higgs, 2005). On this basis, a single strategy of either hypothetico-deductive reasoning or pattern recognition reasoning cannot be considered as superior to one another. Integrated client-centred model of clinical reasoning was proposed as researchers and practitioners searched for the basis in which they could intervene in the clinical practice. This model depicts clinical reasoning as a process of reflective inquiry, in partnership with client, in an attempt to seek and promote deep contextual understanding of the clinical problems. The newer models of clinical reasoning are a break from the cognitive models of understanding clinical reasoning. In an attempt to answer the questions whether physiotherapy students need to have more understanding of the paradigm shift in the clinical reasoning, Kempainen, et al. (2003) asks what the fundamental differences exist in terms of clinical reasoning in the field of physiotherapy. Although related fields such as nursing and occupational therapy have vast literature related to clinical reasoning, there is an obvious paucity in the field of physiotherapy.
According to Kuiper and Pesut (2004) most of the limited studies on clinical reasoning in physiotherapy have been conducted in manipulative therapy or outpatient orthopaedic settings, which represent only a small part of the entire physiotherapy studies and practice. Consequently, there is the need to look through the profession in the perspective of post graduate physiotherapy students to supplement what is already available in the physiotherapy literature. The corresponding aspect in the clinical reasoning in the allied health professions, such as occupational therapy have, in several occasions descried their understanding of clinical reasoning as incomplete without corresponding allied fields such as nursing and physiotherapy (Edwards and Richardson, 2008) or lacking in uniformity (Herbert, et al., 2008, p.183). It is thus clear that even in exploring clinical reasoning in physiotherapy, there is “a shared field of study between the allied health professions”, which also gives rise to a shared field of study in health service (Jones and Rivett, 2004, p.121).
2.2.4 Perception Strategies and Clinical Reasoning
Jones (1992, cited in Jones and Rivett, 2004, p.136) proposed a model of clinical reasoning in the manipulative physiotherapy. This theory had a number of new concepts on several earlier physiotherapy research as well as theory in clinical reasoning (Norman, 2005). First was the common perception that physiotherapists usually generate hypothesis in several other areas of practice and not just in the common area of diagnosis). This idea had been illustrated in the field of occupational therapy, and commonly expressed in the form of procedural reasoning, which gave rise to a number of hypotheses related to cause as well as nature of various functional issues. Others, however, were generated to provide guide to possible options for treatment.
Paterson and colleagues had proposed that a number of hypothesis categories be utilised in the manipulative therapy practice, which includes “sources, contributing factors, precautions and contra-indications to examination and treatment, management and prognosis” (Paterson et al., 2002, p.11). Each of the stated manipulative therapy practice represents different areas of examination or treatment in which to continue to draw hypothesis for testing. In addition, they form a structural base from which knowledge can be significantly organised. Moreover, one crucial concept was that generating and testing hypothesis should be a continuous as well as cyclical in many treatment sessions rather than in a single treatment session. This concept reinforces the idea that clinical reasoning, as observed in physiotherapy, is more to do with the ongoing management in the same breath as it is about initial diagnosis. It is important to make further points regarding hypothesis as well as categories. First, one must note those hypotheses are propositional, hence open to revision. In this dimension, new hypothetical categories have been introduced to further facilitate the understanding of physiotherapy and its dimension. For instance, the hypothesis and mechanism of pain and dysfunction (Jones et al 2000) are some of the common examples in a progressive continuing process. A second aspect is that they have been projected with the field of physiotherapy in mind, thus the need to set physiotherapy practice as a conceivable idea to organise information gathering as well as knowledge in a quite different way (Jones et al 2000). This is an aspect that is currently untested by research, and this study will attempt address it, at least partially.
2.2.5 Development of Clinical reasoning for students in Physiotherapy
The notion that ‘hypothesis categories’ in physiotherapy have demonstrated how allied health professionals have adapted clinical reasoning to the realities of physiotherapy practice is prominent in the general practice of clinical reasoning. ‘Hypothesis categories’ in essence, holds to the idea of ‘hypothetico-deduction’, which forms the primary mode of reasoning as practiced this field (McNair, 2005).
Literature on narratives of postgraduate physiotherapy students’ experience in use of clinical reasoningphysiotherapy is scarce. Barry (1998, cited in Kempainen, 2003, p.178) conducted a study to investigate the responses of 52 undergraduate physiotherapy students by administering a series of questions from a hypothetical patients suffering from back pain. The result showed that nearly all the students’ responses had certain relevant narrative elements in the categories of allied health practices. His conclusion was that there is probably a link between patients’ injury related beliefs as well as the explanations from the health professionals. Other than focusing on undergraduate students who are seen to have far less learned experience even in terms of academic exposure, this research only offered a superficial concept of students’ perception. Monstrum (1999) conducted an ethnographic research, where a portrait of expert neurological physical therapist Caitlin’s clinical work was used. His subjects of study were undergraduate students collected from all the field of clinical practices. Findings indicate that Caitlin was an expert of exchanging stories with his clients. All the same, Mostrum’s conclusion was that stories provided excellent opportunities to have a new or improved understanding of the ill patients’ needs, perspectives, and experiences (Mostrum1999, p. 222).
Edwards (2002, p.32) conducted a qualitative study with the help focus group discussion as a tool for collecting data, and discovered a specific form of knowledge used in clinical reasoning, proposing that knowledge which is derived through research is important in the effective implementation of clinical reasoning among the practitioners. According to the study, it requires the implementation of an interpretive or critical paradigm to get the value of clinical reasoning instilled in the minds of physiotherapists, something that is inherently lacking in novice physiotherapistsIn other words, the study unravelled the form of non-propositional knowledge mainly refers to practice and experience.
2.2.6 Factors that influence the developing of clinical reasoning
Studies have shown the significance of patient- physiotherapist relationship towards successful outcomes in therapeutic process (Bleakley, 2005). Stenmar and Nordholm (1994) surveyed 187 Swedish physiotherapists, and found out that majority of the them focused onto their interpersonal interaction with their patients at the expense of the manual skills they possess when analysing the success or failure of their treatments (Parry, 2004). The conclusion, however, was not considered in relation to clinical reasoning. In fact, the only study that had something related to clinical reasoning provided a reminder of the cognitive tradition’s dominance in the field of physiotherapy. Thompson et al (1997) conducted a study, which measured empathy between novices and more experienced physiotherapists at both the levels of clinical and non-clinical setting. The findings revealed that empathy did not have an obvious impact in terms of increases with increasing years experience in the field of practice. While offering various explanations, there researchers pondered over the question on whether it was the clinical reasoning process itself that worked against the physiotherapists’ empathy in the overall analysis. Some of the questions Thompson and his colleagues asked was whether it is possible that the hypothetico-deductive process of clinical reasoning is wholly immersed in problem solving that it actually interferes with any attempted attention toward emotions as well as feelings (Thompson et al, 1997, p.178). This question was important because, as earlier stated, novice physiotherapist practitioners including students tend to mainly on hypothetico-deductive process. In this study, however, researchers did not consider the possibility that physiotherapists do reason in other ways, just like their nursing counterparts.
In the early teaching and patient education clinical reasoning study, May (1983, reported in Noll and Jensen, 2001, p.46) conducted a survey involving 585 physiotherapists and clinical administrators of accredited physiotherapy education programs in the United States. The survey aimed at determining the attitudes toward teaching as a skill in the field of physiotherapy. Results suggested that although 99 percent of the respondents had strong beliefs that teaching was a critical skill in their respective practice, only 34 percent were prepared with undergraduate skills for it. In this aspect, the study outlined that there is still massive lack of emphasis in physiotherapy in the clinical reasoning perspective (Noll, et al., 2001). In essence, an interactive rather than passive learning has been proven to have greater efficacy (Boshuizen, et al., 1992). 2.2.6. Clinical Reasoning and Evidence based Practice
There is unilateral understanding that the modern day clinical reasoning is political, economical, professional and scientific in context, and is based on evidence of research. Evidence-based approach generally refers to the integration of the best available evidence from various research studies. Clinical reasoning process can be affected by decrease in government healthcare funding, increased costs of healthcare and advancement in technology (Higgs and Edwards, 1999). Today, there is a greater demands placed on practitioners to be more effective and efficient in their practice by governments and management, irrespective of the practitioners’ experience. Evidence-based, hence, is a strategy proposed to provide efficient and effective practice that meets these demands. Evidence-based approach is not only advocated as the preferred model of practice in physiotherapy but is also viewed as the only means of providing proper integrated service in the entire health related services.
The components for evidence-based decision-making process are: evidence based on research, clinical judgement, and patient values integration (Portney, 2004). Portney (2004) further proposed that therapists should integrate their clinical judgement together with the needs of the patients and other unique characteristics towards decision-making process in relation to patient’s treatment and care. Despite the fact that what constitute evidence, in addition to how to access it are elaborated in the literature, how to apply clinical judgement as well as experience to integrate this evidence with the needs of the patients needs and values to make decisions about patients care is not well documented. It is thus prudent to say that clinical reasoning is the channel needed for the successful integration of the evidences.
For instance, Ajjawi and Higgs (2007) conducted a study to highlight the difference between experts and novice in the perspective of clinical reasoning in the field of physiotherapy. Surveying 109 respondents, their conclusion was that expert physiotherapists demonstrate extensive knowledge of the clinical reasoning model, and as such knowledge is usually obtained through practice (Ajjawi and Higgs 2007, p.622). They also found out that the significance of knowledge embedded in expertise is fundamental to the development and expansion of the profession. They further propose that similar knowledge may be used in different teaching and learning contexts to benefit novice physiotherapists. Jones et al (2006) studied what aspect of learning leads to less experienced physiotherapists’ transition to expertise. In the study, different criteria have been identified as being used in an attempt to define expertise in physiotherapy. These researchers also identified peer recognition of expert physiotherapists as one of the approaches that has been properly used to make adequate clinical decisions. Other criteria are represented by the specific number of years spent in the precise field and educational qualification. Nonetheless, providing a definition based on the number of years may be problematic because an excessive number of working experience is not necessarily associated with expertise.
One of the key features of evidence-based practice is its ability to encourage professionals to take a critical view of their practice, especially on decisions based on patient management, in the dimensions of research findings. In this way, novice practitioners, including postgraduate students are stimulated to question their habitual decisions and to seek new knowledge to inform their decisions. Practice based on evidence also informs the dynamic, ever-changing nature of knowledge and the need for them to maintain current knowledge base to continue working efficiently and diligently.
However, evidence-based approach to clinical reasoning practice is largely reliant on the assumption that if evidence from research demonstrates that a particular treatment is most effective for a particular population then it is the most rational treatment approach to implement across the board, or at least in a similar demographic population. These generalisations made from statistical inferences and large amount of data leaves individual viability as obscure as it can be viewed (Jones et al., 2006). The goals, values and preferences as may be seen from individual patients are necessary to determine appropriate intervention and management strategies. Values and beliefs of patients, particularly in relation to their health and management preference may conflict with research evidence, thus creating a dilemma for a physiotherapy practitioner relying on evidence-based practice model. This can even be more complex for physiotherapy postgraduate students or novice therapists.
Literature on clinical reasoning has largely been focused on clinical skills of physicians and medical students in terms of observable behaviours in the dimensions of general skills. The challenge associated with this approach is based on the overreliance on precognitive and process oriented mechanism. While it is understandable that clinical reasoning is a complex process for novice practitioners, including postgraduate students in the United Kingdom, one question that this research endears itself into answering is what creates this complexity to an extent that inexperience practitioners cannot effectively and efficiently practice. Some of the key explanations that have been provided are the features of clinical reasoning that makes up its definition. First, clinical reasoning is considered to be a combination of process and outcome, as well as being interactive in nature. Second, choices of the patients are central to the process of decision making, and lastly is the fact that broad outcome is part of reasoning process and is directly related to meaning constructions, negotiation of goals and management of decisions.
There are various models that have been proposed to form the basis of clinical reasoning. These models are: hypothetico-deductive reasoning model, pattern recognition, and client-centred integrated model. Hypothetico-deductive model relies on information from the patient as gathered and used to undertake hypothesis. Hypothesis of this model is usually confirmed by how patients respond to treatment, which leads to a repeated assessment. One of the limitations of the limitations of hypothetico-deductive model is that it is only used retrospective protocol, which has a tendency for subjects not to give accurate account of what they actually did or thought at the time of diagnosis process. Pattern recognition is clinical reasoning model based on pattern recognition in clinical presentations. This model requires that a similar case should be used to decide whether a process should be undertaken or not. The limitation of this model is the inconsistencies on how it is interpreted when put into practice by different practitioners. Lastly, the integrated client-centred model heralded a shift in paradigm, because hypothetico-deductive reasoning model and pattern recognition model were felt to be insufficient. There is the general agreement that clinical reasoning in physiotherapy requires a broader understanding of political, economic, professional and scientific contexts. To understand these aspects, there is need for evidence-based.
However, the literature analysis in this study clearly indicate that there is gap in literature as far as perception of postgraduate physiotherapy students is concerned within the complex nature of clinical reasoning. Novice practitioners, physiotherapy students included, are not considered in many studies despite the fact that the expectations from them in terms of delivery are not lesser than those placed on experienced physiotherapy practitioners. Moreover, this literature analysis reveals that there is high level of generalisation in the practice of clinical reasoning, a fact that may not augur well for postgraduate student practitioners and novices in general. In addition, experienced practitioners are found to be more accurate, logical and efficient in clinical decision-making than novice practitioners, largely due to their many years of experience. Investigating the perception of physiotherapy postgraduate students towards clinical reasoning will create a structure for learning models to boost the novices’ experience, in addition to adding to a body of knowledge more understandings of clinical reasoning in physiotherapy practice.
Ajjawi, R. and Higgs, J. (2007). ‘Using Hermeneutic Phenomenology to Investigate How Experienced Practitioners Learn to Communicate Clinical Reasoning’, Qualitative Report, Vol. 12(4) pp612-638.
Bleakley, A. (2005). ‘Stories as Data, Data as Stories: Making Sense of Narrative Inquiry in Clinical Education’, Medical Education, Vol. 39(5) pp534-540.
Bleakley, A., Farrow, R., Gould, D. and Marshall, R. (2003). ‘Making Sense of Narrative Inquiry in Clinical Education’, Medical Education, Vol. 39(5) pp534-540.
Bolander, K., Josephson, A., Mann, S. and Lonka, K. (2006). ‘Teachers Promoting Expertise in Medical Education: Understanding the Role of the Core Curriculum’, Quality in Higher Education, Vol. 12(1) pp41-55.
Doody, C., and McAteer. M. (2002). Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy, 88(5), 258-268.
Dunphy, B. C. and Williamson, S. L. (2004). ‘In Pursuit of Expertise: Towards an Educational Model for Expertise Development’, Advances in Health Sciences Education, Vol. 9(2) pp107-127.
Edwards, I. C. (2001). Clinical Reasoning in Three Different Fields of Physiotherapy: A Qualitative Study, Unpublished PhD Thesis, the University of South Australia.
Edwards, I. C. and Richardson, B. (2008). ‘Clinical Reasoning and Population Health: Decision Making for an Emerging Paradigm of Health Care’, Physiotherapy Theory and Practice, Vol. 24(3) pp183-193.
Hayes, B., and Adams, R. (2000). Parellels between clinical reasoning and categorisation. In J. Higgs and M. Jones (Eds.), Clinical Reasoning in the Health Professions (2nd ed., pp. 45-53). Oxford: Butterworth-Heinemann.
Herbert, R. D., Jamtvedt, G., Mead, J. and Birger Haden, K. (2005). Practical Evidence-Based Physiotherapy, London, Elsevier.
Higgs, J. (2004). Educational theory and principles related to learning clinical reasoning. In M.A. Jones & D.A. Rivett (Eds.), Clinical Reasoning for Manual Therapists (pp. 379-402). Edinburgh: Butterworth-Heinemann.
Higgs J, Jones MA. (2000).Clinical reasoning in the health professions. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Boston, Mass: Butterworth-Heinemann, (2) 1:3–14.
Higgs J., and Hunt A. (1999). Rethinking the beginning practitioner: introducing the “Interactional Professional.”. In: Higgs J, Edwards H, eds. Educating Beginning Practitioners. Melbourne, Victoria, Australia: Butterworth-Heinemann: 10–18.
Higgs, J., and Ajjawi, R. (2006). Advanced in clinical reasoning research. Paper presented at the PA NSW Branch Conference: Paving the way with evidence, Sydney, Australia.
Jones, M., Grimmer, K., Edwards, I., Higgs, J. and Trede, F. (2006). ‘Challenges in Applying Best Evidence to Physiotherapy’, The Internet Journal of Allied Health Sciences and Practice, Vol. 4(4) pp1-9.
Jones, M. A. and Rivett, D. A., eds. (2004). Clinical Reasoning for Manual Therapists, London, Butterworth-Heinemann.
Kempainen, R. R., Migeon, M. B. and Wolf, F. M. (2003). ‘Understanding Our Mistakes: A Primer on Errors in Clinical Reasoning’, Medical Teacher, Vol. 25(2) pp177-181.
King, C.A., and Bithell, C. (1998). Expertise in diagnostic reasoning: A comparative study. British Journal of Therapy and Rehabilitation, 5(2), 78-87.
Kuiper, R. A. and Pesut, D. J. (2004). ‘Promoting Cognitive and Metacogntive Reflective Reasoning Skills in Nursing Practice: Self-regulated Learning Theory’, Journal of Advanced Nursing, Vol. 45(4) pp381-391.
MacDougall, J. and Drummond, M. J. (2005). ‘The Development of Medical Teachers: An Enquiry into the Learning Histories of 10 Experienced Medical Teachers’, Medical Education, Vol. 39 pp1213-1220.
May, S., Withers, S., Reeve, S., and Greasley, A. (2010). Limited clinical reasoning skills used by novice physiotherapists when involved in the assessment and management of patients with shoulder problems: a qualitative study. The Journal of Manual and Manipulative Therapy, 18(2): 84-88.
McNair, R. P. (2005). ‘The Case for Educating Health Care Students in Professionalism as the Core Content of Interprofessional Education’, Medical Education, Vol. 39(5) pp456-464.
Noll, E., Key, A. and Jensen, G. (2001). ‘Clinical Reasoning of an Experienced Physiotherapist: Insight into Clinician Decision-Making regarding Low Back Pain’, Physiotherapy Research International, Vol. 6(1) pp. 40-51.
Norman, G. R. (2005). ‘Research in Clinical Reasoning: Past History and Current Trends’, Medical Education, Vol. 39(4) pp418-427.
Parry, R. H. (2004). ‘Communicating During Goal-Setting in Physiotherapy Treatment Sessions’, Clinical Rehabilitation, Vol. 18(6) pp668-682.
Paterson, M., Higgs, J., Wilcox, S. and Villeneuve, M. (2002). ‘Clinical Reasoning and Self-Directed Learning: Key Dimensions in Professional Education and Professional Socialisation’, Focus on Health Professional Education: A Multi-disciplinary Journal, Vol. 4(2) pp5-21.
Portney, L.G. (2004). Evidence-based practice and clinical decision making: It’s not just the research course anymore. Journal of Physical Therapy Education, 18(3), 46-51.
Ritchie JE. (1998). Building a customer perspective into evidence-based physiotherapy practice. In: Proceedings of the Fifth International Congress of the Australian Physiotherapy Association; Hobart, Tasmania, Australia.Vol 1. Hobart, Tasmania: Australian Physiotherapy Association (Tasmanian branch): 97–99.
Rivett, D., and Higgs, J. (1997). Hypothesis generation in the clinical reasoning behaviour of manual therapists. Journal of Physical Therapy Education, 11(1), 40-45.
Shaw, J. A. and DeForge, R. T. (2012). ‘Physiotherapy as Bricolage: Theorizing Expert Practice’, Physiotherapy Theory and Practice, Vol. 28(6) pp420-427.
Smith, M., Higgs, J. and Ellis, E. (2008). ‘Characteristics and Processes of Physiotherapy Clinical Decision Making: A Study of Acute Care Cardiorespiratory Physiotherapy’, Physiotherapy Research International, Vol. 13(4) pp209-222.
Tan, S. M., Ladyshewsky, R. K. and Gardner, P. (2010). ‘Using Blogging to Promote Clinical Reasoning and Metacognition in Undergraduate Physiotherapy Fieldwork Programs’, Australasian Journal of Educational Technology, Vol. 26(3) pp355-368.