Pediatric Physiotherapists Clinical Reasoning and ICF Essay
However, clinical knowledge implies to both theoretical and practical understanding of clinical aspects as is necessary for professionalism. The clinical practice knowledge is either propositional or non-propositional where propositional is more theoretical hence; scientific while non-propositional is based on experience (Lee, 2011, p. 1-2).
Competence, on the other hand, refers to the professional requirement that a person properly performs a specific job (Boshuizen and Schmidt, 1992, p. 153-155). In reference to the clinical field, competence, therefore, would imply the professional requirement that a medical practitioner, especially at the clinical level has high command ineffectiveness of performing specific jobs, often the health care service delivery. Clinical reasoning, on the other hand, refers to the capacity of a clinical practitioner to think of a clinical matter logically for making an informed judgment for a conclusion.Pediatric Physiotherapists Clinical Reasoning and ICF Essay. This, therefore, shows an increased capacity for a person to think as well as understand clinical practice matters logically for effectiveness in the profession.
The definitions of knowledge, reasoning as well as competence revolve around understanding and effectiveness in clinical professional practice (Rich, 1991, p. 319-325). There is, therefore, an association between knowledge, competence as well as reasoning knowledge would be pointed out to emanate from the capacity to reason and apply skills developed through competence in the clinical field. In the acquisition of knowledge, complex processes of cognitive capacity coupled with the ability to apply higher reason in decision-making are involved. Moreover, the capacity of one to perform clinical practices with ease and effectively as defines competence contributes to gaining knowledge and can also be said to emanate from performing clinical duties with knowledge. Besides, clinical practices as termed as scientific involve the application of scientific knowledge that requires competence and reasoning for experimentation purposes.
The conceptual frameworks of the International Classification of Functioning, Disability and Health (ICF) and the recently published International Classification of Functioning, Disability and Health – Children and Youth (ICF-CY) provide pediatric physical therapists with an effective way to document and evaluate the assumptions inherent in their clinical decision making. This paper discusses some of the clinical assumptions made in pediatric physical therapy and provides examples of how to identify and to document these assumptions using the ICF framework. Pediatric Physiotherapists Clinical Reasoning and ICF Essay.These clinical assumptions may be valid, and the ICF provides a mechanism to make them more transparent and to systematically evaluate them. Other uses of the ICF discussed in the literature are also presented. Perceived barriers to clinical implementation of the ICF and future uses of the ICF framework in clinical practice are also discussed.
Clinical reasoning refers to the thinking and decision-making processes that are used in clinical practice. 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. Over the last decade, clinical reasoning has come to prominence as a subject for study. This has occurred, in part, because of the skills expected of physical therapists and development of the profession in a changing health care climate that requires increasing accountability in decision making as part of the process of providing desirable outcomes.1 Another reason for the rising importance of clinical reasoning is that independent and responsible decision making is now regarded as one of the characteristics of an autonomous profession.2,3 In addition to these reasons to justify the importance of clinical reasoning, clinical reasoning is relevant because every physical therapist has to make a wide variety of decisions in his or her daily clinical practice. All clinicians, therefore, have an interest in improving their decision making. Reflecting on decision making is part of a sound clinical reasoning process and is an important source of learning in practice.1
Early studies and models of clinical reasoning in physical therapy provided explanations of clinical reasoning that were similar to those of physicians and were mainly concerned with “diagnosis.”4–9 The common factor was support of the hypothetico-deductive model of reasoning. The hypothetico-deductive model remains the most enduring clinical reasoning model in medicine and was derived from a cognitive science perspective.10 In the hypothetico-deductive method, the clinicians attend to initial cues (information) from or about the patient. From these cues, tentative hypotheses are generated. This generation of hypotheses is followed by ongoing analysis of patient information in which further data are collected and interpreted. Continued hypothesis creation and evaluation take place as examination and management are continued and the various hypotheses are confirmed or negated. Pediatric Physiotherapists Clinical Reasoning and ICF Essay.
The hypothetico-deductive reasoning model, although derived from cognitive science, has its roots in the empirico-analytical research paradigm.11 The empirico-analytical research paradigm, which is also known as the scientific or positivist paradigm, holds that truth or reality (ie, knowledge) is objective and measurable, thereby utilizing observation and experiment to produce a result that, in turn, can be generalized and also leads to prediction. For example, randomized controlled trials are carried out within this paradigm of research. In clinical practice in physical therapy (as in medicine), hypothetico-deductive reasoning aims, within the limitations of available standards, to validate information or data acquired from the patient through measurement in a reliable fashion.
Other models of clinical reasoning from this same cognitive science (empirico-analytical) perspective have focused less on the processes and more on the organization and accessibility of knowledge stored in the clinician’s memory. Examples of knowledge organization used in clinical reasoning include “illness scripts”11 and “pattern recognition.“12,13 In making use of illness scripts or pattern recognition, the clinician recognizes certain features of a case almost instantly, and this recognition leads to the use of other relevant information, including “if-then” rules of production, in the clinician’s stored knowledge network.14 This form of reasoning moves from a set of specific observations toward a generalization and is known as “forward reasoning.“12Forward reasoning contrasts with hypothetico-deductive reasoning where a person moves from a generalization (multiple hypotheses) toward a specific conclusion.14Experts generally agree that both forms of this cognitively oriented reasoning are used at different times.10,15 Pattern recognition is faster and more efficient and is used by expert and experienced practitioners in their domain.14 Hypothetico-deductive reasoning is used by more inexperienced practitioners and by experts when faced with an unfamiliar problem or a more complex presentation.10,15 These 2 cognitively oriented methods taken together are often referred to as “diagnostic reasoning.”4,5,16,17
Until the mid-1990s, the forms of clinical reasoning discussed were the main forms of reasoning described in the physical therapy literature. Researchers of expertise and clinical reasoning in physical therapy,18–20 nursing,21–26 and occupational therapy27–31then began to consider alternative methods for studying the development of expertise and the nature of clinical reasoning. In each field, engagement with the patient and family, as compared with the emphasis on the initial diagnosis, in our opinion, led clinicians to ask different kinds of questions regarding the nature of patients’ experiences of pain, illness, and disability. That is, many of the clinical tasks in these health care professions required an understanding of the person as well as the disease.25,27 This understanding raises a “world” for the patient that has both biomedical and lived experience. Pediatric Physiotherapists Clinical Reasoning and ICF Essay. This polarity has been described in the medical, adult learning, and sociological literature.32–36
Most of the clinical reasoning research carried out up to this point had been in the laboratory rather than at the actual site of practice.37 Researching clinical practice from the site of clinical practice, by including the perspectives of clinicians and patients, would require a paradigm of research that could include many variables over most of which the researcher would have little control.38,39 In contrast to the empirico-analytical research paradigm, an interpretive research approach recognizes that truth or knowledge is related to meaning and the context in which it is produced and, therefore, concedes that in any given situation there may be multiple realities, truths, or perspectives.11
The explanations of clinical reasoning emanating from this collective research in the interpretive paradigm in the health care professions are said, by their various proponents, to stand in contrast to hypothetico-deductive or diagnostic reasoning. 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. Such interpretations (albeit not necessarily consciously constructed) may not be neutral in their effects on the teller.40,41 In the context of clinical practice in physical therapy, narrative reasoning concerns the understanding of patients’ stories in order to gain insight into their experiences of disability or pain and their subsequent beliefs, feelings, and health behaviors.27,40 This includes the patients’ ability to make choices and learn new perspectives.35 Patients’ narratives, therefore, may provide insights for intervention and its outcomes.41Narrative reasoning is distinguished from hypothetico-deductive reasoning in that “hypotheses” concerning patients’ interpretations of their experiences are not validated by testing but by consensus between therapists and patients.27. Pediatric Physiotherapists Clinical Reasoning and ICF Essay.
Influenced by the critical social theory of the German philosopher Habermas,33Mezirow35 distinguished between different forms of learning: instrumental learning and action, and communicative learning and action. Instrumental learning and action (like hypothetico-deductive reasoning) has as its purpose the determination of cause-effect relationships, which lead to predictions about observable events that are either correct or incorrect. The aim of communicative learning and action, however, is not to establish cause-effect relationships but to increase insight and a common understanding of a situation through a mutual learning process between the therapist and the patient.
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
Not only were the early studies of clinical reasoning in physical therapy more concerned with the diagnostic process, the majority of these studies were carried out in orthopedic settings.4,5,18,41–45 Physical therapist practice, however, occurs across a wide spectrum of health care and, as a profession, requires solving complex and poorly defined practice problems.36 In an Australian setting alone, a person could consider the range of skills needed, to do rehabilitation among aboriginal people in remote areas, cardiothoracic physical therapy in an acute hospital, orthopedic (manual) physical therapy in a private practice, physical therapy for children with orthopedic problems, or physical therapy aimed at helping retrain motor skills in adults following a stroke. The breadth and variation in the skills required, as the demands of each area are considered, is vast. Pediatric Physiotherapists Clinical Reasoning and ICF Essay.
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. 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. 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.
We believe there is a need, therefore, for identification of the range of clinical reasoning skills or strategies being utilized by experts in different aspects of physical therapy care. This process of identification, we contend, is important as the profession considers the variety and scope of its activities and seeks to answer questions such as, “How will physical therapy define itself and its role(s) in the community in an increasingly competitive health care market?” and “How can future practitioners be best educated and prepared to function in the various fields of health care in which physical therapists practice?”
The aim of our study was to examine the nature and scope of clinical reasoning and knowledge used by expert clinicians in 3 different fields of physical therapy: orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (or home health) physical therapy. Our objective was to generate further theory concerning clinical reasoning in physical therapy. We also sought to develop a new model to explain the clinical reasoning already in use among physical therapist clinicians. Due to the large body of data generated by our study, we will concentrate on reporting the findings in terms of the nature, scope, and manifestation of the clinical reasoning skills of the therapists. We will refer only briefly as to how the knowledge for these skills is acquired.
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. 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. Pediatric Physiotherapists Clinical Reasoning and ICF Essay/ Jensen et al identified the following as attribute dimensions that distinguish between master and novice clinicians: (1) ability to control the treatment environment, (2) wide use of patient illness and disease data in a context-rich evaluation, (3) focused verbal and nonverbal connection with the patient, (4) equal importance of teaching to hands-on care, and (5) confidence in predicting patient outcomes.
The grounded theory approach and case study work are both methods that seek to understand human behavior within a natural context and from the participants’ point of view.38,39,46 The phenomenon studied is clinical decision making, and the context is the clinical practice in which this decision making takes place. Each of the 6 physical therapists in the primary sample, together with their clinical practices, constitutes a “case” for study.
Grounded theory is a field-based research technique that seeks to generate theory.46Although 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. 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). Each conceptual framework is the result of a continued refinement of data collection, data analysis, and reference to existing theories in various fields of relevant literature.
The 3 fields of orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (home health) physical therapy were chosen for our study because they represent quite diverse areas of physical therapist practice from which we could investigate the formation of potentially different domains of knowledge and reasoning skills. Pediatric Physiotherapists Clinical Reasoning and ICF Essay. 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. The 6 physical therapists were selected by a purposive50 or critical case sampling method.47
Australian Physiotherapy Association (APA) consultants are prominent physical therapists appointed to act as public spokespeople for the profession on account of their current standing and expertise in their respective fields. The APA consultants for each field were contacted and asked to nominate, based on criteria of expertise (Fig. 1), a short list of physical therapists regarded by their peers as experts in their particular fields. Not all of the characteristics described in Figure 1, however, are operationally defined. The consultants were asked to nominate only physical therapists whom they felt possessed at least 5 of the 7 criteria. Two physical therapists from each list were selected at random, and all therapists agreed to participate in the study. An information sheet was sent to each therapist before confirming his or her participation and signing consent forms. These 6 primary informants had clinical practice experience ranging from 13 to 33 years (Tab. 1). All therapists had current or past teaching experience and either held postgraduate qualifications or were engaged in formal postgraduate study.Pediatric Physiotherapists Clinical Reasoning and ICF Essay.
|Years Since Graduation||Work Setting||Teaching Experience||Qualifications|
|Denise*||14||Domiciliary care/senior PT||Supervision of final-year students||BAppSc, MAppSc candidate|
|Danielle*||13||Domiciliary care/senior PT||Supervision of final-year students||BAppSc Grad Dip
|Dianne||31||Community health center||Supervision of final-year students||Dip PT|
|Dorothy||30||Community health center||Supervision of final-year students||Dip PT|
|Neve*||33||Neurophysiotherapy/private practice principal||Clinical tutor–undergraduate course||Dip PT, Dip Psychosynthesis|
|Narelle*||12||Neurophysiotherapy/private practice principal||Clinical tutor–undergraduate course||BAppSc, MAppSc|
|Nancy||28||Associate professor||Lecturing, research||Dip PT, BA, PhD|
|Nicole||14||Senior lecturer||Lecturing, research||BAppSc, PhD|
|Michael*||22||Manipulative PT/principal private practice||Lecturer–postgraduate courses Dip PT, Grad||Dip Manip Ther, MAppSc (physio)|
|Monica*||15||Manipulative PT/principal private practice||Tutor postgraduate course in manipulative therapy||BAppSc, Grad Dip Manip Ther|
|Meredith||16||Manipulative PT/principal private practice||Tutor postgraduate course in manipulative therapy||BAppSc, Grad Dip Manip Ther|
|Marion||14||Manipulative PT/principal private practice||Tutor postgraduate course in manipulative therapy||BAppSc, MAppSc, PhD candidate|
Asterisk denotes participant in primary sample. PT=physical therapist.
In this article, the physical therapists are identified by pseudonyms, with the first letter of these pseudonyms also being the first letter of the field in which they work (eg, Neve is a neurological therapist). 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.
Data collection took place, in the manner of grounded theory, in 3 “waves” over the course of approximately 1 year. The first data collection consisted of observation of treatment sessions and semistructured and unstructured interviews (see Fig. 2 for sample questions). Each physical therapist was “shadowed”51 over the course of 2 or 3 days of their usual work. The orthopedic and neurological physical therapists were all observed in the rooms of their private practices. The domiciliary care (home health) physical therapists were observed during visits to the homes of their patients. Pediatric Physiotherapists Clinical Reasoning and ICF Essay.