Clinical Reasoning in Physiotherapy: Perceptions of Postgraduate Student Physiotherapists Doing Msc. in UK   

Abstract

            Clinical reasoning is an extremely fundamental aspect of clinical competence among physiotherapists. However, there is limited research regarding how postgraduate students doing their Masters degree understand and develop this cardinal component. This research aims at exploring the current perceptions held by Masters postgraduate students in the UK. A qualitative research approach will be used and there will be 240 participants from the University of Cambridge and University of Oxford. The interviews will be videotaped for better analysis and future reference.

 

Table of contents

Introduction…………………………………………………………………4

Overview and background…………………………………………………..4

Problem statement…………………………………………………………..4

General statement of the aims……………………………………………….4

Significance of the study…………………………………………………….4

Literature review……………………………………………………………..4

Summary of the literature…………………………………………………….6

Methodology…………………………………………………………………6

Research approach……………………………………………………………6

Data collection methods………………………………………………………6

Sampling strategy……………………………………………………………..7

Recruiting the participants…………………………………………………….7

Required number………………………………………………………………7

Inclusion and exclusion criteria………………………………………………..7

Materials……………………………………………………………………….7

Data analysis methods…………………………………………………………7

Sources of bias………………………………………………………………….8

Role of researcher………………………………………………………………8

Safety issues and Risks…………………………………………………………9

Ethical issues……………………………………………………………………9

Possible limitations………………………………………………………………9

Conclusion………………………………………………………………………9

Reference list……………………………………………………………………10

Appendices……………………………………………………………………..11

1. Interview Schedule……………………………………………………..11
2. Informed consent letter…………………………………………………12
3. Study timetable …………………………………………………………14

 

 

 

 

Introduction

Overview and background

Clinical reasoning is the decision making and thinking process that is used in clinical practice. Physiotherapists are required to link theory and practice since past experiences and present knowledge are necessary in making any decision. It is imperative for any physiotherapist to have advanced skills in clinical reasoning. These decisions involve the care, management, and treatment of patients (Anderson, 2005: 105). In this regard, a physiotherapist can be able to explain and justify to patients why he used particular treatment plans (Larin, Wessel & Al-Shamlan, 2009: 39). This ensures that the best decisions are made, which is vital for the provision of quality patient care. Clinical reasoning is also considered to be a cardinal component for all physiotherapists’ clinical competence. Usually, clinical decisions are made after considerations of a patient’s physical and clinical conditions (Zayas & Lietz, 2010: 197).  This study was considered necessary following the concerns of musculoskeletal clinical teachers regarding the level of variability of clinical reasoning skills among postgraduate students across the curriculum. The variability was most evident during the second year of the students’ masters program.

Problem statement

            Clinical reasoning is a process that takes place during every interaction a physiotherapist has with patients as well as significant others including health team members and carers (Larin, Wessel & Al-Shamlan, 2009: 56).  In addition, clinical reasoning is cardinal when devising management strategies and treatment plans and this is based on professional judgment, patient choice, knowledge, experience, and clinical data. During the process, a certain treatment intervention is selected over other possible options and it continues throughout unending patient management. This points out how vital clinical reasoning is among physiotherapists. Using a phenomenographic perspective, a wide array of research indicates that learning conceptions among students influences their learning manner. Students who perceive learning to be repetitive memorization have a higher likelihood of using simple strategies and, therefore, conceptualize the topic in a limited way. On the other hand, students who learn with an intention of understanding of understanding the topic have higher tendencies of engaging in activities that achieve more sophisticated conceptualization and promote understanding (Larin, Wessel & Al-Shamlan, 2009: 47).  This gives the implication that how physiotherapy postgraduate students conceptualize clinical reasoning is likely to impact on their manner of reasoning in clinical settings. Research examining the manner in which clinical reasoning is comprehended and perceived among physiotherapy postgraduate students is limited (Zayas & Lietz, 2010: 201).

General statement of the aims

            The aim of this study is to explore the present understanding on clinical reasoning among postgraduate students, the perceptions they hold, and how these are acquired.

Research Questions

1. Why is there variability in the level of clinical reasoning skills among postgraduate students?
2. What are the factors that contribute to this variability?
3. What are the impacts of this variability in management strategies and treatment plans?
4. How do students conceptualize clinical reasoning?
5. How are the conceptualizations acquired? (Anderson, 2005: 105).
6. How can the results of the study be used to improve the teaching curriculum?

Significance of the study

Knowledge of the variations and nature of perceptions in regard to clinical reasoning among postgraduate physiotherapy students is vital in designing useful teaching curriculums. Teaching can only become a rational activity when the instructor comprehends how and what students conceptualize or discern the phenomenon being imparted on them (Ramklass, 2013: 8).

Literature review

Novice practitioners as well as postgraduate students mostly use the hypothetical-deductive strategy of clinical reasoning. This approach is considered to be weak since the practitioner usually focuses on the superficial issues. Novice practitioners as well as postgraduate students use this strategy as they consider it to be the best considering their limited non-propositional knowledge (Larin, Wessel & Al-Shamlan, 2009: 62).

For physiotherapists to be able to deliver safe and effective care, there is a need for additional categories (Crawford, Fazey & Singer, 2010: 59). Therapists with varying training are likely to ask questions that differ. In addition, they will conduct different tests depending on the significance accorded to physical and subjective information availed by the patients. However, regardless of these variations, the questions asked by physiotherapists aim at reaching a common goal; understanding and managing the patient’s problem. Physiotherapists acquire this information based on the symptom’s source or dysfunction, contributing factors, contraindications and precautions to treatment and physical examination, management, and prognosis. It is worth noting that the mentioned categories are not specific to any approach or physiotherapy philosophy (Hendrick et al., 2009: 438).  Any physiotherapist using the hypothetical-deductive clinical reasoning cannot underrate these categories.

Regardless of the fact that epidemiological studies offer insight into the possible cause of various injuries and diseases, physiotherapists have a role of informing patients the level to which their disorder in agreeable to physical therapy as well as the estimated timeframe for which recovery is possible (Jensen et al., 2000: 29). Therefore, the prognosis category can be made based solely on every patient’s individual presentation. So as to be able to receive information that leads to various hypothesis categories, there is a need to use both physical and subjective examination (Ramklass, 2013: 5).

Conducting routine treatment plans that are not linked to previous patient examination requires physiotherapists to have clinical reasoning skills. It is extremely important to use data generated from patient interviews in generating problem statements and establishing measurable goals. Treatments should be made based on the generated hypothesis. Physiotherapists should also be able to reassess the impacts of the implemented treatment (Hendrick et al., 2009: 440). This algorithm helps is teaching the hypothetical- deductive clinical reasoning method as well as helping clinicians to identify instances where their actions are not formulated logically.

Physiotherapists recommend a model that emphasizes on hypothesis modification, testing, and generation, and this should be incorporated throughout the entire encounter with a patient. This also includes physical examination, interview, and ongoing management (Jensen et al., 2000: 35). It is worth pointing out that the clinical reasoning process depicts a cyclical character and the process also has phases that are influenced by numerous key factors. The first step in the clinical reasoning process requires the therapist to observe and interpret the patient’s initial cues. These steps should also encompass the opening moments where the therapist greets the patient (Ramklass, 2013: 7).There should be observation of particular cues including the resting posture, movement patterns, facial expressions, appearance, age, and all spontaneous comments. These cues enable the therapist to come up with an initial concept regarding the problem. This also should involve preliminary working hypotheses that will be considered throughout the entire examination as well as during the ongoing treatment (Jensen et al., 2000: 40). A majority of the curriculum frameworks recommend that there should be a reciprocal link between postgraduate and clinical settings (Sole et al., 2013: 63). An addition, the frameworks assert that strong links are necessary between practice and theory. Rarely do postgraduates use pattern recognition due to limited experience and knowledge and this may lead to disregard of contextual information. A majority of the physiotherapists hold the notion that the physiotherapy setting determines the decisions that are made (Ramklass, 2013: 4). For instance, physiotherapists working in the musculoskeletal setting are more oriented towards functional or movement problems and, therefore, there may be difficulties identifying other vital problems. On the same note, physiotherapists working in the pediatric, geriatric, or neurology environment tend to emphasize more on the client’s psychomotor, social, and psychological status (Crawford, Fazey & Singer, 2010: 64).

The reflections and perceptions of more experienced practitioners and students vary from novice students who are beginning their clinical experience. Mostly, novices and students who are unable to modify treatment sessions during their practice use reflect-for-action and reflect-on-action (Hendrick et al., 2009: 441). A majority of the physiotherapists hope to improve their clinical reasoning skills with continued practice. Errors made during a session can be a tool for cultivating better clinical reasoning skills and reflecting on modifications that are likely to better future sessions (Zayas & Lietz, 2010: 189). On the contrary, experts possess the ability of adapting treatment procedures in a session to fit the patient.

Summary of the literature

Clinical reasoning is a very vital strategy in physiotherapy since it guides practitioners in the decisions they make, offering the most relevant treatment plan, and putting all individual aspects into consideration. There is a need for practitioners to possess in-depth non-propositional and propositional knowledge, sociocultural and psychological knowledge, and immense experience. These are the ingredients for sound clinical reasoning. Clinical reasoning is a thinking that is essential for guiding practice. Narrative reasoning is acknowledged to be very crucial in informing practitioners about patient attitudes, emotions, beliefs, and feelings, and these have an impact on patient outcomes and treatment interventions (Hendrick et al., 2009: 435). Continuous reflection is important in that it leads to initiation of alternative treatments that can suit the patient and maximize his outcomes.

There are several clinical reasoning models that are basically founded on the analysis of patient and clinician interactions (Anderson, 2005: 105). These are extremely important and relevant to physiotherapy. They include narrative reasoning, diagnostic or hypothetico-deductive reasoning, and pattern recognition.

Methodology

Research approach

            An interpretive and qualitative approach founded on phenomenography principles (internal relationship, 2^nd-order perspective, and experience structure) will be used in the research. As far as 2^nd-order perspective is concerned, category meanings will be defined based on students’ explanations of clinical reasoning conceptualizations as opposed to definitions obtained from previous researches. The structure and meaning of students’ conceptualizations will be accessed through questions regarding what they comprehend in regard to every aspect and how this is understood (Zayas & Lietz, 2010: 193).

Data collection methods

The postgraduate students will participate individually in a semi-structured, audiotaped, in-depth interview at the middle of their second year after all practical sessions and lectures involving clinical reasoning are over. The interviews will be scheduled to occur within three weeks following completion of the MS clinical placement. The interviews will take from 5 to 12 days. The study will be conducted by a PhD student who has a science background. So as to ensure that procedural reliability and validity are maintained during the study, the interview questions will be reviewed regularly to ensure that their answers relate to the purpose of the study. In addition, there will be continuous checks during analysis (Crawford, Fazey & Singer, 2010: 52).

Basically, the interviews will concentrate on what the students comprehend and the manner in which they carry out their practice. Participants will be requested to elaborate their practice examples and describe how they understand clinical reasoning, clinical information or knowledge as well as learning, including how that understanding is achieved. The audiotapes will be transcribed verbatim and the researcher will check the transcripts against the audiotapes before beginning data analysis.

Sampling strategy

The study will comprise of 10 physiotherapy postgraduate students from Queen M. University in the UK. The students will be in their second year of Masters study. Each of the students will be required to give their perceptions regarding clinical reasoning in physiotherapy. The participants will be grouped based on their area of expertise; neurological, musculoskeletal, and cardiopulmonary physiotherapy. These three practice fields will be chosen since they represent cardinal physiotherapy areas of practice as acknowledged by the United Kingdom Physiotherapy Council. In addition, the participants will be grouped based on their sex (Sole et al., 2013: 60). This constitutes stratified sampling where participants are stratified into groups depending on similar features so as to facilitate comparisons and illustrate subgroups.

Recruiting the participants

Students will be given adequate information regarding the research during lectures at the start of their second year in master’s degree. The students will also be guaranteed that failing to participate in the research will not bear any effects on their assessment results or grades. They will, therefore, be asked to volunteer.

Required number

10 participants from Queen M. University will be adequate to provide sufficient data in the research. Participants will be assessed to determine their perceptions on clinical reasoning and how they acquire them (Jones, 1992: 881).

Inclusion and exclusion criteria

During the selection of participants, those who have English as their second language will be excluded. In addition, postgraduate students who are not through with their MS clinical placement by the year of the study will also be excluded. Students who practice in the neurological, musculoskeletal, and cardiopulmonary fields will be selected to participate in the study and their inclusion will ensure diverse clinical practice setups and, therefore, it will be easier to explore clinical reasoning skills and perceptions.

Materials

The research will be funded by the Research into University Teaching grant. Adequate time will be dedicated so as to ensure quality research (Crawford, Fazey & Singer, 2010: 59).

Data analysis methods

During every analysis stage, the researcher will explore the data separately while searching for evidence that does not confirm to evolving categories and themes (Adams, 1981: 32). The researcher will assess and address his assumptions in regard to evolving categories and themes regularly. This will be a strategy for ensuring trustworthy data representation. The base analysis unit will comprise of the entire student’s transcript. The analysis will involve three stages;

First, there will be a crude initial sorting and reading where individual transcripts will be read and grouped based on similarities and differences (Bialocerkowski, Golding & Delany, 2013: 47). This will ensure that there is easier access to the complex and huge amount of data. Second, there will be a refined categorization where transcripts in every group will be subjected to a more detailed analysis. There will be a keen analysis of various aspects regarding students’ conceptual fields and these will be compared to other aspects so as to come up with the meanings that students link to knowledge, learning, patient care, practice, and clinical reasoning (Jensen et al., 2000: 39). This analysis will be aimed at revealing what students understand regarding clinical reasoning (meanings ascribed to the whole and parts), each aspect’s structure (how experiences will be described), and the potent logic or rationale for the link between aspects (the reason why students comprehended experiences in the manner they will describe them). Transcategory and intracategory differences and similarities will be identified and compared. There will be a continuous revisitation of the emerging categories and these will be adjusted so that they are considered in the data using the above described disconfirmation process. Detailed descriptions of every category will be prepared (Bialocerkowski, Golding & Delany, 2013: 47). The criteria used for allocating categories will be identified, and the experiences of every individual will be checked against the criteria and category description. Finally, completed category descriptions will be subjected to meta-analysis with the aim of identifying general themes that were evidenced in various forms across categories (Sole et al., 2013: 59).

Sources of bias

The researchers will consider measures that would inhibit bias (Sran & Murphy, 2009: 236). The researcher will audit the evolving categories and themes. He will achieve this through checking them regularly against the raw data as a strategy of promoting validity. Several strategies such as disconfirmation and audit trails are some of the means through which robustness and credibility of the data analysis and research process will be promoted. Category descriptions will be subjected to audit as well as peer review in two seminars. Each of the seminars will have twenty five physiotherapy faculty staff members and academic staff members, and this will be conducted at the proposed location of the research. The audience will be required to give their feedbacks and these will be noted and included in the research. The researcher will verify clinical reasoning conceptualizations as well as cross-category themes based on his clinical reasoning experiences in physiotherapy curriculum (Sran & Murphy, 2009: 241).  He will review audit trails and ensure a step-by-step cross-examination of the associated documents and research process.

Role of researcher

Data will be mediated through the researcher; human instrument. The researcher will be required to elaborate relevant self aspects, as well as assumptions and biases, experiences that qualify his ability in conducting research, and any expectations. The qualitative researcher will be required to keep research journals that explicit personal reflections and reactions and insights into the past and self. The researcher will also be required to mention if they are emic (insider) or etic (outsider). He will ask probing questions, then listen, think, and later ask more probing questions so as to engage a deeper conversation. The researcher will build a picture through the use of theories and ideas from numerous sources. He will also be responsible of ensuring that validity and reliability are maintained (Bialocerkowski, Golding & Delany, 2013: 47).

Safety issues and Risks

The research will adhere to the protocols of ethical research practice so as to ensure the well-being and safety of the participants (Sran & Murphy, 2009: 237). Regardless of the fact that this is a qualitative research and only minimal risks can occur to the participants, any risks that are likely to occur will not be disregarded. The research is a bit sensitive and will touch on taboos and personal issues, which might pose threats to the participants. The researchers will also be keen on maintaining safety. Measures will be put in place to avoid wider risks to the researcher’s discipline, institution, and field of study (Adams, 1981: 39).

The participants will have the benefits and risks of participating elaborated to them as a component of the consent procedure. This will ensure that they put this into consideration when deciding if to participate or not. Risks will be assessed during the entire research. During the dissemination and publication of the research, risk considerations will be addressed. When conducting the interviews, the researcher will be sensitive to the feelings of participants and any discomfort or distress they experience will be solved appropriately. In this research, it is expected that there will be more emotional than physical risks. The researchers will also be keen on noting physical signs so as to identify where participants need to elaborate more or when the interview should be stopped (Jones, 1992: 877).

Ethical issues

            Before the study is conducted, a copy of the proposal will be presented to the Human Ethics Committee so that they grant their approval. Participants will take part in the research voluntarily and confidentiality will be guaranteed (Jones, 1992: 882). No real names of the participants will be used.

Possible limitations

Regardless of the fact that the results of the study may inform Masters postgraduate students in the United Kingdom, their application to PhD postgraduate students should be made with extra caution. The research design used is inappropriate in identifying a developmental trend. The development of clinical reasoning as well as its influences can only be investigated through the use of longitudinal studies that track how individual students progress in different physiotherapy disciplines including neurorehabilitation. The research will be conducted on a volunteer basis and this gives the implication that many students will disagree to participate. According to Adams (1981: 76), student recall bias and volunteer basis might influence the responses students will give regarding patient-related questions. Therefore, these might influence the distribution of clinical reasoning conceptualizations (Jones, 1992: 876).

Conclusion

In the past, clinical reasoning perceptions were not explored qualitatively through the use of direct experience from students as the data. There is a need for further research of this nature and in particular, longitudinal studies. These will offer a novel way through which perceptions on clinical reasoning can be explored as well as insight into its assessment, teaching, and development. There is a need for constant assessments regarding students’ understanding at a specific period during their study. This knowledge is extremely important to students and teachers in student learning advancement.

 

Reference list

Adams, P 1981, Effective teaching of tertiary learners: strategies and faculty development implications, University of Lethbridge, New York.

Anderson, LW 2005, ‘Objectives, Evaluation, and the Improvement of Education,’ Studies in Educational Evaluation, vol. 31, pp. 102- 113.

Bialocerkowski, A, Golding, C & Delany, C 2013, ‘Teaching for thinking in clinical education: Making explicit the thinking involved in allied health clinical reasoning,’ Focus on Health Professional Education: A Multi-disciplinary Journal, vol. 14 iss. 2, pp. 44- 56.

Crawford, RJ, Fazey, PJ & Singer, KP 2010, Teaching and learning in postgraduate manual therapy education: Perspectives on clinical supervision. In Educating for sustainability. Proceedings of the 19th Annual Teaching Learning Forum, 28-29 January 2010. Perth: Edith Cowan University.

Hendrick, P, Bond, C, Duncan, E, & Hale, L 2009, ‘Clinical Reasoning in Musculoskeletal Practice: Students’ Conceptualizations,’ Physical Therapy, vol. 89 iss. 5, pp. 430-442.

Jensen, GM, Gwyer, J, Shepard, KF & Hack, LM 2000, ‘Expert practice in physical therapy,’       Physical Therapy,  vol. 80 iss. 1, pp. 28-43.

Jones, MA 1992, Clinical Reasoning in Manual Therapy, PHYS THER. Vol. 72, pp. 875- 884.

Larin, H, Wessel, J & Al-Shamlan, A (2009), ‘Reflections of physiotherapy students in the           United Arab Emirates during their clinical placements: a qualitative study,’ BMC            Med     Educ., vol. 20: iss. 3, pp. 34- 67.

Ramklass, S 2013, ‘The clinical Education Experience of Student- Physiotherapists within a Transformed Model of Healthcare,’ The Internet Journal of Allied Health Sciences and Practice, vol. 11, iss. 2, 1-9.

Sole, G, Schneiders, A, Hebert-Losier, K & Perry, M 2013, ‘Perceptions by physiotherapy students and faculty staff of a multimedia learning resource for musculoskeletal practical skills teaching,’ New Zealand of Physiotherapy, vol. 41 iss. 2, pp. 58- 64.

Sran, MM & Murphy, S 2009, ‘Postgraduate Physiotherapy Training: Interest and Perceived Barriers to Participation in a Clinical Master’s Degree Programme,’ Physiother Can., vol. 61 iss. 4, pp. 234–243.

Zayas, LE & Lietz, CA 2010, ‘Evaluating qualitative research for social work practitioners,’ Advances in Social Work, vol. 11 iss. 2, pp. 188- 202.

 

 

 

 

Appendixes

Interview Schedule

1. This first question addressed all about you. Give me a little information about yourself. How old are you? Where are you from? Why did you decide to do physiotherapy?
2. Which is you field of practice?
3. You have just completed you MS clinical placement. I would request you to reflect about the placement. Then select a certain patient you dealt with and are comfortable discussing.

Depending on the response given, some of the probable probes include the following;

1. Tell me about the patient.
2. What problem did the patient have?

• Why have you preferred discussing this particular patient?

1. What were you thought on interacting with the patient for the first time?
2. How did you respond to the situation?
3. What was the reason behind this reaction?

• What were your conclusions?
• What drove you to those conclusions?

1. Can you elaborate on the process through which the conclusions were reached?

 

4. What do you understand by the term clinical reasoning?
5. Can you elaborate more?
6. Can you give an example where clinical reasoning is essential in physiotherapy practice?
7. Why do you think it is necessary?

 

5. Can you provide an example where you were required to use you clinical reasoning skills during practice?
6. Elaborate more about the situation; what took place?
7. Were you skills productive?

 

6. Why is clinical reasoning necessary during practice?

 

7. What did you acquire and develop your clinical reasoning skills?
8. Can you elaborate more about that?
9. What factors affected the development?
10. Has the development changed? How?
11. Has physiotherapy curriculum impacted on these skills in you?

 

8. What do you think clinical knowledge means?

 

9. How is learning achieved in the clinical area?

 

1. What does learning mean to you?

 

1. What questions, suggestions, comments, or concerns do you have?

 

 

 

Informed consent letter

Title of the study: Clinical Reasoning in Physiotherapy: Perceptions of Postgraduate Student       Physiotherapists Doing Msc in UK

Researcher:

Name

Department

Address

Phone number

Email

Background:

This is an invitation for you to participate in a research. Before making the decision to participate, it is crucial that you comprehend the reason as to why the research is being conducted and all that it involves. Therefore, I request that you read this information keenly. Kindly ask any questions or clarifications that may arise. If you need more information, contact the researcher.

 

The study is aimed at exploring the present understanding on clinical reasoning among postgraduate students, the perceptions they hold, and how these are acquired.

 

Study Procedure

You will be expected to dedicate 30- 60 minutes of you time to answer the interview questions. The study will be elaborated more during lectures and the participation is voluntary.

 

Risks

There are minimal risks related to this research. The risks are the same as those experienced when revealing work-related concerns to others. Some of the questions in the study may make some participants emotional particularly those connected to their experiences. You can decline answering some the questions and if there are pressing concerns, you are also free to terminate participation.

 

Benefits

There shall be no direct benefit for volunteering to participate in the study. However, it is hoped that the questions and responses given will enable the participants to reflect more about their practice. No monetary compensation will be given to the participants.

 

Confidentiality

Kindly note that no identifying information should be released during the interview. The responses should be anonymous.

 

Consent

My signature on this consent form confirms that I have read and comprehended the information and will, therefore, take part in the study. I understand I can withdraw in case I have any pressing concerns and the participation is voluntary. I also understand that a copy of this consent form will be given to me. I will participate in the study voluntarily.

 

Signature…………………………..                                       Date ……………………..

 

 

 

 

Study timetable

Activity	Estimated Timeframe
Develop research objectives	I day
Design research protocol	2 days
Designing the instrument	4 days
Recruit participants	2 weeks
Pretesting and revising the instrument	5 days
Collect data	5- 12 days
Transcribe recordings	1 week
Data analysis	2 weeks
Prepare the presentation	3 days
Present the preliminary results to the committee	1 day
Prepare the report	1 week
Present the report	2 days