Chapter 9 Dimensions of clinical reasoning capability
In the context of our complex healthcare environment, most clinical situations are characterized by varying levels of certainty and agreement as to the appropriate or ‘right’ decision to be made and course of action to be undertaken. This uncertain and at times unpredictable practice environment presents many clinical reasoning challenges, even for experienced clinicians. When we consider the array and magnitude of potential challenges this same practice context poses for less experienced or new clinicians, the need is clear for a focus on the development of capability in clinical reasoning during professional entry educational programmes.
This chapter draws from findings of a doctoral research project undertaken by Christensen, in collaboration with Jones, Edwards and Higgs, which explored how the development of capability in clinical reasoning can be facilitated in the context of professional entry physical therapist education (Christensen 2007). This research employed a hermeneutic approach to the interpretation of texts constructed from previously published literature and transcribed records of interaction with research participants. The research involved focus group and individual interviews with student physical therapists who were nearing the completion of their respective professional education programmes at four different physical therapy schools in California. Here, we introduce and discuss the concept of clinical reasoning capability, one of the main outcomes of this research. Ways in which students can be guided towards development of that capability during the professional entry education process are discussed in Chapter 36.
In our explorations we adopted the term capability from the higher education literature. Capability was defined by John Stephenson (1992, 1998) as the justified confidence and ability to interact effectively with other people and tasks in unknown contexts of the future as well as known contexts of today. Stephenson (1998, p. 2) explained that ‘to be “justified”, such confidence needs to be based on real experience’. Specifically, capability is observed in confident, effective decision making and associated actions in practice; confidence in the development of a rationale for decisions made; confidence in working effectively with others; and confidence in the ability to navigate unfamiliar circumstances and learn from the experience (Stephenson 1998).
In their phenomenological study of professional doctoral students in a work-based learning programme, Doncaster & Lester (2002) sought to understand what is involved in being and becoming capable. They concluded that capability may best be conceptualized as ‘an “envelope” or complex bundle of abilities and attributes which is personal to individual practitioners, and which is exercised in equally personal ways in relevant contexts’ (p. 98). Participants’ descriptions of ‘being capable’ included both ‘outer’ and ‘inner’ dimensions. The outer dimension of capability was linked with action; capable action involved initiating or managing change, especially in difficult or complex contexts. Closely related to this was the ability to work effectively with others to effect change through collaboration and consensus. The inner dimensions of capability varied considerably among participants, but Doncaster & Lester identified several commonly recognized qualities and skills that contributed to effectiveness. Specific examples were the ability to get things done, leadership ability and ability to inspire others into action in support of ideas and goals. All of these abilities required skills in communication, listening, facilitation, tact, persuasion and the ability to work with others. Other key elements of capability included intellectual or thinking abilities, such as critical thinking, reflection, synthesis, creativity, evaluation and intuition. Closely related to these were breadth and depth of understanding in action, involving the ability to see the big picture, understand the wider context and wider implications (of policies or actions) and engage in systems thinking.
Capability, then, cannot be precisely defined and therefore cannot be tied to a list of profession-specific technical skills and abilities, characteristic of ‘capable practice’. Rather, high-level capability results when practitioners have opportunities and resources for professional growth, encounter events or circumstances that spur them to action in this regard and are motivated to succeed or change in their practice (Doncaster & Lester 2002). In other words, capable individuals are skilled experiential learners. Capable individuals are motivated to develop their knowledge intentionally, through application and processing of their knowledge via reflective learning from practice.
Clinical reasoning is a process that links and integrates all elements of practice (such as philosophy of practice, generation and use of practice knowledge, profession-specific technical skills, communication and collaboration, ethics and identity). Within clinical reasoning, these integrated elements are brought to life and developed. Capability in clinical reasoning involves integration and effective application of thinking and learning skills to make sense of, learn collaboratively from and generate knowledge within familiar and unfamiliar clinical experiences.
Our recent research has identified that key elements of capability are directly applicable and recognizable in the clinical reasoning of skilled and experienced physiotherapists, and that capability in clinical practice is best observed through the clinical reasoning of skilled clinicians (Christensen 2007). Descriptions of characteristics of the clinical reasoning and practice of expert physiotherapists (Edwards et al 2004, Jensen et al 1999) show deep similarities to descriptions of performance of capable individuals: for example confidence and effectiveness in decision making, in providing contextual justification for actions and decisions, in motivating self and others, in communicating and collaborating with others to effect change and in critical, reflective thinking.
There are also similarities between capability and the Aristotelian notions of practical knowledge and reasoning, and obvious links to descriptions of the application and generation of practice knowledge in the clinical reasoning of skilled practitioners (Higgs et al 2004). Practical reasoning involves the application of both theoretical knowledge and, most significantly, experiential knowledge. A key feature of practical reasoning is that this experiential knowledge is both applied to and arises from practical activity, and is open to revision or expansion by processing new experiences in light of past experiences (Gadamer 1989). Practical reasoning is highly contextualized in that it is applied to concrete situations and results in particular actions relevant to the specific situation(s).
Another key feature of practical reasoning is that it is inherently ethical in nature. This is because it requires subsequent decisions for action, decisions that are determined by close consideration of the broader moral and ethical issues at play in the context of a particular situation (Dunne 1993). This action is oriented towards ‘doing the right thing’ based on taking all situational variables and constraints into account (Gadamer 1989, Schwandt 2001). Recently authors have described the practice of expert physiotherapists as profoundly influenced by their context, ethics, values and virtues (Edwards et al 2005, Jensen & Paschal 2000). Likewise, capability is observed when we see people ‘taking effective and appropriate action within unfamiliar and changing circumstances’, which ‘involves ethics, judgements, the self-confidence to take risks and a commitment to learn from the experience’ (Stephenson 1998, p. 3).
The clinical reasoning process is the ‘navigation system’ upon which skilled clinicians can confidently rely for direction in decision making and action, in both familiar and unfamiliar clinical situations. ‘Justified confidence’ in thinking, learning and associated actions is the hallmark of capability and is developed through successful experience in living out, or putting into action, what one knows (Stephenson 1998). Capability is characterized by the confidence to take risks, to try new things in practice and to make mistakes. Clinical reasoning provides a firm foundation for practice, not only for making decisions in uncertain situations and trialling new procedures but also for prompting reflection and learning from practice experiences both familiar and innovative.
Clinical reasoning is the vehicle for experiential learning from practice; it is well accepted that the process of thinking about one’s own thinking and the factors that limit it facilitates learning from clinical practice experience (Eraut 1994, Higgs & Jones 2000, Schön 1987). Thus, clinical reasoning serves to develop as well as to demonstrate practice capability.
Experiential learning is a goal of capable action and results from translating knowledge and reason into action in the context of living and working with others (Stephenson 1998). A key element in any individual embodiment of capability is the motivation and skill to learn through experiences in any (known or unknown) situation. Christensen (2007) found that capability in clinical reasoning was observed in clinicians who were confident in their skills and motivated to continually learn from collaborative work with patients in practice. We propose that clinical reasoning capability develops from, and contributes to, skill in collaborative clinical reasoning and experiential learning from reasoning experiences. Capable practitioners have been described in the literature as skilled and motivated experiential learners (Doncaster & Lester 2002, Stephenson 1998). Capable clinical reasoners, then, are skilled and motivated to learn from experience through intentional reflective processing of their reasoning in practice (Christensen 2007).
The research reported in this chapter (Christensen 2007) showed that capable clinical reasoners demonstrated sound thinking and learning skills. Dimensions of clinical reasoning capability, as discussed below, can be interpreted as being congruent with the descriptions of clinical reasoning of expert physiotherapists in recent research-based literature (Edwards et al 2004, Jensen et al 1999). These dimensions were often underdeveloped, disconnected, or absent in the conceptions of and reflections on clinical reasoning of the student physical therapist research participants studied by Christensen. The limited connection between these thinking and learning skills in the understandings of, and reflections on, clinical reasoning of most of the student physical therapists participating in the study served to highlight the lack of adequate attention to the learning of clinical reasoning in their professional educational journeys and clearly indicated the importance of developing the clinical reasoning skills of capable practitioners.
Given that capability has been described as a complex and multifaceted construct, not amenable to descriptions of specific technical skills or qualities, we suggest that the dimensions of clinical reasoning capability discussed here are not a comprehensive set of dimensions. Nor can they completely comprise the capable individual clinical reasoner’s ‘envelope’ or bundle of abilities and qualities. They have been chosen for their pivotal role in the reasoning of skilled practitioners and for the type of thinking in clinical reasoning that facilitates experiential learning. Learning from clinical practice requires thinking and learning skills to be integrated and applied to both the doing of the clinical reasoning (for example dialectical thinking, complexity thinking) and the processing of the experience of clinical reasoning (for example reflective thinking, critical thinking, complexity thinking). The four dimensions of clinical reasoning capability described here are reflective thinking, critical thinking, dialectical thinking, and complexity thinking.
The process of reflection relates to clinical reasoning of a practitioner, both when engaged with a patient over a period of time, considering and evaluating performance in past experience, and also in an immediate sense, reflecting in the moment while working with a patient. Schön (1987) described two types of reflection in practice that illustrate this distinction as reflection-on-action and reflection-in-action.
Reflection-on-action refers to thinking back on experiences ‘to discover how our knowing-in-action may have contributed to an unexpected outcome’ (Schön 1987, p. 26). In this sense, reflection becomes a way of cognitively organizing experience through construction of a sense of coherence, and facilitating planning for future action (Forneris 2004).
Reflection-in-action, as described by Schön (1987, p. 26), is reflection that occurs in the midst of action, without interruption of the action upon which the practitioner is reflecting. He described this type of reflection as thinking that modifies what is being done while it is being done, and which can thus impact on the situation at hand while it is still being experienced. Some scholars, however, have expressed concern about identifying as reflection this phenomenon that is characterized by the rapidity and relative superficiality with which someone can truly reflect on a situation while engaged in action (Eraut 1994, Van Manen 1995). Eraut (p. 149) suggested that this sort of reflection is more accurately viewed as a metacognitive activity than a reflective one. On the one hand this disagreement is about terminology; on the other it relates to the nature of reflection and metacognition as phenomena. In this chapter we propose that a heightened level of awareness involving critique of one’s thinking and other actions (which we have previously called ‘metacognition’; see Higgs & Jones 2000) is an essential element of sound clinical reasoning. This behaviour broadens the ‘bigger picture’ focus of experiential learning engendered by (after the event) reflection-on-action to also include the potential to learn from the smaller decisions and critiques within practice. Such reflective self-awareness (metacognition) facilitates concurrent learning within the details and patterns of response to individual decisions, actions and procedures in practice.
It is important to differentiate the process of reflection, as discussed above, from the process of critical reflection. The following section details critical thinking and describes the role of reflection in critical thinking in practice.