This meant that when listening to the audiotapes later, there was a written commentary supplying both contextual information and a workable “index” to material on the audiotapes—an important factor for coding and the later construction of case studies. Grounded theory is a field-based research technique that seeks to generate theory.46 Although there is a debate among proponents of grounded theory concerning the level of preconceived theory with which a researcher enters the field, there is general support for the idea that theory that is generated from the data should be compared with or contrasted to existing theories (if they exist).46–48 An important feature of grounded theory, therefore, is the iterative relationship among data collection, data analysis, and review of the literature. Theorizing is a process whereby alternative explanations or models are considered. Besides technical skills, cultural, social, and personal knowledge and understanding together with diagnostic, teaching, negotiating, listening, and counseling skills might all play a greater or lesser role in the clinical reasoning process. Domiciliary care therapist Denise taught Mr H, who had a stroke, how to get up and down off a chair independently. Hudson Jones C Over the last decade, clinical reasoning has come to prominence as a subject for study. 3). Although 2 or more clinical reasoning strategies may be in operation concurrently and there may be overlap between the reasoning strategies (eg, interaction and collaboration), each clinical reasoning strategy requires an orientation of thinking and action, which is not wholly subsumed by the others. Narelle has just had to pilot her way through a situation where, she needed to acknowledge J's disappointment and Bob's burning anger toward the surgeon and surgical management of J's aneurism. Man Ther. . S Afr J Physiother. Her patient, N, had a particularly aggressive form of multiple sclerosis. J's husband, Bob, is in attendance. , Guba EG. This quantitative expression of symptoms, which might last several minutes over the duration of the technique, was far removed from any narrative component. However, all of the reasoning strategies illustrate the dialectical nature of the physical therapists' reasoning and can be found in more detail online in the non–peer-reviewed doctoral dissertation on the research project.58 Diagnostic and narrative reasoning, being well documented in the clinical reasoning literature and having been explained in the background section, will not be further dealt with here, although patient stories (or fragments of them) are included as examples in the reasoning strategies of interaction, teaching, and ethics. Code of Conduct.  |  In communicative learning and action, the learner (either therapist or patient) when confronted by an unfamiliar experience or dilemma (eg, in a patient's case, ongoing pain, disability) becomes aware through critical reflection of the underlying assumptions or perspectives that he or she holds about particular situations (eg, past experience and beliefs concerning injury or physical therapy intervention).35 The capacity to first understand the perspectives a person currently holds, then reflect on the adequacy of these perspectives, and finally adopt newer, more constructive or reliable perspectives is called “transformatory learning.”35. YS She chooses to contradict the medical “defense.” Narelle has been a witness in this situation to a narrative protesting the havoc of iatrogenesis (or medically induced harm to the patient). This was despite the fact that prior to the telephone call, she had been working on N's foot. 5 | Academy of Pediatric Physical Therapy Fact Sheet/Resource Teaching Clinical Reasoning Skills in the Clinic and the Classroom Whether in the clinic or in the classroom, clinical reasoning is often best taught in the context of patient care and 22clinical cases. J: No, you can't tell. 1), a short list of physical therapists regarded by their peers as experts in their particular fields. Greenhalgh The 2 research paradigms (as discussed in the introduction) generate knowledge from different assumptions about the nature of reality. So it's not the whole story of headaches, but sometimes the teeth clenching can be a problem, especially if there is a lot to do and not a lot of time to do it in. Kleinman G Each case study was sent, on completion, to the respective therapist from the primary sample for his or her comments, a process known as “member checks.”52 On follow-up, which was done via a telephone conversation, each therapist responded very positively to the question, “Was the case study a fair and accurate interpretation of their clinical work with its particular characteristics, emphases, and values?”. Benner The breadth and variation in the skills required, as the demands of each area are considered, is vast. Proceedings of the APTA Conference on Clinical Decision Making in Physical Therapy Practice, Education, and Research; October 2–5, 1988; Osage Beach, Missouri. Bob: Oh bitter? Within these clinical reasoning strategies, the application of different paradigms of knowledge and their interplay within reasoning is termed "dialectical reasoning.". Higgs and Jones1 have defined clinical reasoning as a process in which the therapist, interacting with the patient and others (such as family members or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgment and knowledge. These therapists used these reasoning strategies in an interplay that was governed by particular patients' needs and their contexts. An audit trail is a record of decision making (either of the primary investigator or of the coding panel), of turning points in the research, of correspondence with various stakeholders, and of cognitive “road maps” summarizing researcher understanding of the project at different points. Following assessment of symptom behavior, T undresses, and “ropes” of paraspinal muscle spasm are noted by Michael. , Hayes Fleming M. Hagedorn A model of clinical reasoning in physical therapy characterized by the notion of “clinical reasoning strategies” is pro- posed by the authors. M: As long as she doesn't come home with a cast on her arm. The story that Neve told M regarding the plasterer with headaches appeared to have the aim of providing her with the insight that people sometimes may be unaware that their own responses, or coping behaviors can contribute to the production or perpetuation of symptoms. Ritchie The clinical reasoning strategy codes were developed by the panel based on Jensen and colleagues' attribute dimensions18 and other described clinical reasoning methods used in health care such as narrative reasoning.27 That is, alongside the existing descriptions of clinical reasoning used in fields such as nursing and occupational therapy, the attribute dimensions provided areas of clinical practice (eg, teaching, psychosocial focus, prognostic ability) among expert practitioners in which to examine foci of clinical reasoning. Methods: Melbourne, Victoria, Australia: Australian Physiotherapy Association; June. Finally, multiple perspectives were considered: the constructed case studies, which were the interpretations of each therapist's clinical practice by the researchers, the corroboration of those case studies by each therapist in the primary sample, together with the views of the second sample of therapists (incorporated in the composite case studies) were all compared with existing models of reasoning from the relevant literature. HHS Yin There's not a lot you can do. From these composite case studies, cross-case analysis, first within settings and then across settings, was performed. Triangulation is an important tool used in an effort to ensure rigor and involves the use of several data sources, methodological approaches, multiple analysts, and the consideration of diverse theories to explain findings in order to reduce systematic bias in the data.50,54 In our study, the different data sources were observation, interview, and written reflection. … I spoke to someone yesterday. , Echternach JL, Riddle DL. JA I don't know what comes first, whether the teeth clenching comes first or the headache. The instrumental and communicative forms of collaboration are not being set against one another, and both could occur within a single treatment session. One example in our study was where the physical therapists expressed regret or failure. Current directions in psychological science, 9 (5), 178-181. The hypothetico-deductive model remains the most enduring clinical reasoning model in medicine and was derived from a cognitive science perspective.10In the hypothetico-deductive method, the clinicians attend to initial cues (informa… This in-depth description reduces the chance that identified elements of observed treatment sessions or interview comments from informants are “taken out of context” to suit the purposes of the researcher. Within these clinical reasoning strategies, the application of different paradigms of … A few minutes into the physical examination, T, himself, provides a cue that Michael immediately follows up: “When I take a deep breath, my pain is eased for a minute.” Michael asks T to demonstrate this, observes the action, and, in response, teaches him how to enhance the effect by contracting the transversus abdominis muscle. Morse Rivett The first data collection consisted of observation of treatment sessions and semistructured and unstructured interviews (see Fig. (Neve, neurological therapist), I tend to let the person guide the interview. He proceeds to carefully re-educate T's lumbar spine movement in various positions by controlling and releasing the lumbar extensor muscles. Methods: Guided by a grounded theory method, a multiple case study approach was used to study the clinical practice of the 6 physical therapists in the 3 fields. Reasoning about teaching is thinking directed to the content, method, and amount of teaching in clinical practice, which is then assessed as to whether it has been effectively understood. Jensen The maneuver—rising from a sitting position to a standing position—required consideration of the possible contribution of several factors affecting its successful completion: Mr H's position on the chair (buttocks forward), the position of his feet, the flexibility of his knees, the height of the chair, and the use of arms to push off. J . A different mix of clinical reasoning skills may be needed for therapists working in the same settings according to their own particular interests, beliefs, or clinical and life experiences. The domiciliary care (home health) physical therapists were observed during visits to the homes of their patients. A We also sought to develop a new model to explain the clinical reasoning already in use among physical therapist clinicians. The research approach we used follows that of Jensen et al.18 Using a grounded theory, case study approach within an interpretive research paradigm (explained in the “Method” section), Jensen and colleagues were the first researchers to systematically study the clinical work of physical therapists in order to differentiate novice practitioners from their expert counterparts. . What occurs now is the combined use of teaching and diagnostic reasoning; one informing the other. And then, at the end, I think we haven't covered shopping or we haven't covered toileting or pressure care or whatever the gaps are. Rather, we contend that our conclusions concentrate on illustrating their intrinsic relationship in clinical practice. Terry, W. (1993). Neve: I've got a daughter who's just finishing nursing, and she's at Repat—the last day of her course. A microcassette recorder with a very small omnidirectional microphone was used. She told me they were going to give her a Betadine† bath to mark the occasion [joint laughter]. , Simons H. Benner Our findings support existing research19,20,26,28 concerning the attention given, and importance attributed, to the interaction between practitioners and their patients in a range of areas such as therapist-patient interaction, collaboration, teaching, and ethical practice. An example of this is found in domiciliary care therapist Danielle's visit to an elderly couple of Croatian origin. Within these clinical reasoning strategies, the application of different paradigms of knowledge and their interplay within reasoning is termed “dialectical reasoning.” Summary of the relationship between knowledge and reasoning paradigms with clinical reasoning strategies. The cassette recorder was attached by Velcro* to the inside of a folder. R I JF Arocha It is not only this transfer of meaning (ie, where the intentions of the therapist and the perspectives of the patient are communicated and mutually understood) but also the transfer of power (ie, the therapist's letting go of a professional “right” to be right in favor of the patient's assumption of a greater voice) that constitutes the move to a communicative approach to collaboration. This course begins the development of critical thinking and reasoning strategies through clinical presentations and management. Denise addressed each factor, hypothetico-deductively confirming or negating the influence of each factor in Mr H's inability to rise from the chair. Predictive reasoning also could be used to assess the potential benefit a person who had a stroke was likely to obtain from physical rehabilitation. Similarly, exploration of a patient's perspectives regarding his or her problem, including the patient's understanding (or beliefs and attributions), expectations, and coping, are examples of narrative inquiry where management directed toward facilitating reflection and consideration of alternative perspectives (by patient and therapist) would constitute communicative management. [addressing J] I'm really going to cut this toe off!  |  The second wave of data collection consisted of written material from each of the 6 physical therapists. This iterative process means that the findings of the study are progressive and represent the development of a series of conceptual frameworks (or interim explanations of the data). 1). Rothstein By the end (perhaps 10 minutes), Mrs G was able to give gentle expression to the tears that had been rising but held so far during the visit. Dussart C, Pommier P, Siranyan V, Grelaud G, Dussart S. J Eval Clin Pract. Professional knowledge refers to forms of practice knowledge, often tacit or intuitive, that also reflect a practitioner's practical and technical expertise. Personal knowledge is experiential knowledge that comes about through the practitioner's reflection on experience (both work and non–work related) and helps form a practitioner's frame of reference or worldview with its particular values. EB We found that all of the observed physical therapists in each of the 3 settings used a range of clinical reasoning skills or strategies representing a diversity of thinking and actions in a variety of tasks and relating to many issues that exist in clinical practice. The determination of the sample size of 6 primary informants (2 clinicians from each field) rested on Kluzel's argument that, “[t]he validity, meaningfulness and insights generated from qualitative inquiry have more to do with the information richness of the cases selected and the observations/analytical capabilities of the research than the sample size.”49, The research panel (consisting of an orthopedic physical therapist who was the primary researcher; 3 other physical therapists with various expertise in qualitative research, adult learning, and teaching; and one other member, a lecturer in ethics) agreed that 6 cases would yield a large and sufficient amount of data. Narelle is able to introduce an experiential component to her response with the introduction of her own sister's experience. Schön For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Reasoning about procedure is the decision making behind the determination and carrying out of treatment procedures. GM Clinical reasoning refers to the thinking and decision-making processes that are used in clinical practice. Patient autonomy, justice, and not doing harm to patients are examples of such principles.60 On the other hand, there is a narrative (or communicative) approach to ethical decision making where the experiential and contextual elements of a given situation (or narrative) guide decisions and actions, in turn, providing perspectives on these broader rules or principles of right and wrong.61. The course is designed to help physical therapists develop consistent systematic clinical reasoning processes to differentially diagnose disorders within the scope of practice of a physical therapist and to recognize disorders requiring medical referral. She also needed to express another perspective about outcomes in such cases. 6. The story provokes reflection by J on her own situation. Best practices and the integration of existing evidence into clinical reasoning, along with strategies for reflection to drive professional growth, will be emphasized. One of their early explanations (or conceptual frameworks) of the differences among orthopedic physical therapists in outpatient settings was that expert clinicians exhibited clinical qualities that differed from those of their novice counterparts. MQ The therapists were told that this was not meant to be a curriculum vitae but rather a personal reflection on those influences, which could include people and events outside the profession. The 6 physical therapists were selected by a purposive50 or critical case sampling method.47. P Clinical reasoning is defined as the process used by OT practitioners to understand the client’s occupational needs, make decisions about intervention services, and think about what we do. The therapists were asked the same sample questions regarding issues of practice as those that the therapists in the primary sample were asked. Data analysis for a study such as ours can be considered having 4 stages: coding, individual case studies, composite case studies (cross-case analysis within settings), and comparative analysis (cross-case analysis across settings). The remaining monographs each cover a major joint region of the body, from the cervical spine and temporomandibular joint to the foot and ankle. What those factors are will need to be explored. Our objective was to generate further theory concerning clinical reasoning in physical therapy. These feelings were pursued and explicated in the case studies. Don't push down at your shoulder! A strong theme in the earlier part of this initial session had been M's poor coping mechanisms and unresolved conflict with other family members. J: Well, I've suffered from headaches since I was 16, well over 30 years, and I'm sure it must have been my aneurism. Seventy-nine treatment sessions were observed across the 3 fields (Tab. However, movement could also, at times, be a highly communicative action where handling, touch, and massage were used to convey therapist attitude or empathy (ie, meaning and intent) and were not assessed in any measurable way. Results. Clinical Reasoning in Physical Therapy: A Concept Analysis - free recording Use of the Dual-Processing Theory to Develop Expert Clinical Reasoning in Physical Therapy Students - free recording Collaborative Clinical Education: Success in the 2:1 Model Webinar - free recording Following consensual validation of these assumptions with their patients, we propose that communicative management then also involves physical therapists fostering a process of critical reflection on the part of patients regarding the reliability and adequacy of those assumptions as exemplified by neurological physical therapist Neve's work with her patient M in facilitating an understanding of her tension headaches. She mildly corroborates J's own statement that “it needed to be done straightaway.” Interestingly, she does not “toe” any professional line as such, feeling content to contradict “Dr Squirrel's” alleged remark that “there's always something goes wrong” with the contrasting example of her own sister. 2020 Apr;15(2):274-286. However, the terms “hypothetico-deductive” and “narrative,” in emanating from the clinical reasoning literature, have traditionally been applied to the process of “inquiry” or diagnosis in clinical practice.10,29 The terms “instrumental” and “communicative,” in emanating from the literature of adult learning, are here applied to a range of learning and action tasks and are therefore, we believe, more appropriately applied to the diversity of clinical management strategies. One such example is narrative reasoning.27 Narrative reasoning seeks to understand the unique lived experience of patients—a reasoning activity that could be termed “the construction of meaning.” In patients' (or therapists' for that matter) telling of stories or narratives, there is a choice in which some elements are expressed, some elements are emphasized over others, and still other elements may not find expression.40 For example, the particular “telling” of a story or history by patients represents their interpretation of events over time. Phys Ther. The third wave of data collection took the form of semistructured interviews with 6 other physical therapists (2 therapists from each of the same 3 fields) 12 months after the initial fieldwork. A retrospective analysis of ethics knowledge in physical therapy (1970-2000). Perhaps the same therapists use different combinations of clinical reasoning skills at different times and occasions according to the particular patient or client and the context of care. C Do I have the operation to cut the aneurism off? These 6 primary informants had clinical practice experience ranging from 13 to 33 years (Tab. The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) illustrates the usage of the International Classification of Functioning, Disability and Health (ICF) model while capturing the complexities of patient-therapist interaction 2. Background and purpose: Clinical reasoning is essential to physical therapist practice. None of the therapists in this primary sample had formal training in clinical reasoning theory. Data collection commenced following approval of the study by the Human Research Ethics Committee of the University of South Australia. It concerns a 17-year-old boy, known to both J and Narelle, and his experience after a subarachnoid hemorrhage 3 years previously. Morse J Thus, the plasterer, who in response to Neve's question, “What do you notice happening?” (when he had these headaches), asked his workmates what he looked like and was told that he “smiled all the time.” The plasterer then realized that he was clenching his teeth, trying to look like he was not in pain, but in doing so was contributing to further headache symptoms. JM It also leads to Narelle being confronted with an ethical dilemma. This site needs JavaScript to work properly. But he asked the people whom he worked with, and he said, “Well, how do I look when I've got a headache?” and they said, “You smile all the time,” and he realized he was clenching his teeth, trying to look like he wasn't in pain … but teeth clenching was really perpetuating the headaches. Subjects: Physical therapists often rely primarily on a specific reasoning strategy; however, both deductive and inductive strategies may be used in different clinical scenarios or when a preferred strategy is not effective for a given situation. , Jones MA. Jones Neck pain in South Africa: An overview of the prevalence, assessment and management for the contemporary clinician. I don't know about the history. Collaboration at such times was necessarily instrumental. Cesario C, Pommier P, Tanner C, Pommier P, Tanner C. Rew L Barrow. Considered coding definitions and identified the resulting constructs from the act of making a diagnosis through management through... ( Michael, orthopedic [ manual ] therapist ), and Ms Carr provided data analysis purposeful. Various forms within the 3 fields was the wonderful setting in which their children grew up the! 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