Chapter 36 Helping physiotherapy students develop clinical reasoning capability
A primary goal of professional entry programmes is to prepare graduates to practise effectively in today’s complex healthcare system. The clinical reasoning and decision making of new graduates can be viewed as a practical demonstration, or outcome, of the professional entry education process. Therefore, we propose that the development of capability in clinical reasoning should be a priority for educators responsible for preparing new members of the profession for practice.
In Chapter 9 we introduced some of the findings of recent research (Christensen 2007) into clinical reasoning capability. Clinical reasoning capability 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. We also described four dimensions of clinical reasoning capability: reflective thinking, critical thinking, dialectical thinking and complexity thinking. We described capable clinical reasoners as having developed a justified confidence in their practice abilities and a strong motivation to learn from experience through intentional reflective processing of their reasoning in practice.
The doctoral research conducted by Nicole Christensen and supervised by the other authors of this chapter (Christensen 2007) used a hermeneutic approach (described in Chapter 9) to explore how the development of capability in clinical reasoning can be facilitated in the context of professional entry physical therapist education. In this chapter we again draw upon the findings of this research, and suggest some ways in which students can be guided towards the development of clinical reasoning capability during their professional entry educational journeys.
Current models of expert physiotherapists’ practice and clinical reasoning (Edwards & Jones 2007, Jensen et al 1999) interpret this phenomenon as inherently complex, demonstrating characteristics of a complex adaptive system. A number of authors have advocated the adoption of a complexity perspective to facilitate understanding and coping with escalating complexity in all subsystems (social, political, professional, human) involved in health care today (e.g. Plsek & Greenhalgh 2001, Zimmerman et al 2001). Professional entry education systems therefore face great challenges in the endeavour adequately to prepare new practitioners who are capable of practising within their professional role and interacting effectively in the larger healthcare environment.
Long before they enter the practice environment, student physiotherapists must learn to successfully negotiate their professional entry education programmes. Graduate and professional education systems have been characterized as complex, inherently challenging and ultimately transformative for learners (Weidman et al 2001). For the student physiotherapist, then, the process of becoming a capable professional (and thus a capable clinical reasoner) depends upon becoming a capable learner within the professional entry education system. Physiotherapy students engage in learning experiences within academic classroom and clinical education settings in which individual students’ learning experiences are quite variable, despite the efforts of individual programmes, national accreditation systems and international standards to provide some degree of consistency in curriculum content and expected outcomes. Both within and between academic programmes, there is considerable variability in the extent of integration of curriculum content (theoretical and technical) and the learning of processes, including clinical reasoning, thinking and learning skills.
Christensen’s (2007) research illustrated this variability in learning experiences, in both academic and clinical education settings, through the different contexts and ways the student participants described learning about clinical reasoning. For example, they described varying levels of explicit exposure to clinical reasoning theory (e.g. learning about what it is, what it involves), and variation in the number of opportunities and the quality and value of their learning experiences in relation to developing clinical reasoning skills. Most notably, these students experienced great variability in clinical education experiences. This is not surprising, since individuals in the programmes in the study (as with many such educational programmes) were commonly placed in different practice situations, under the supervision of a variety of clinical educators, all with different levels of skill in and understanding of clinical reasoning. The clinical educators also varied in their level of skill in facilitating students’ clinical reasoning skills development through experiential learning opportunities and in enhancing their learning from clinical reasoning practice experiences.
Overall, Christensen (2007) found that the learning and practice of clinical reasoning was often a self-directed journey for the participants, some ultimately and inevitably more capable in their learning than others. Since the learning programmes studied largely devolved (mainly incidentally rather than intentionally) the responsibility for learning clinical reasoning to the students, the question of the responsibility of educators to teach clinical reasoning explicitly was highlighted. Another key finding was that the role of chance or ‘luck of the draw’ in providing students with opportunities to develop their clinical reasoning capability was even more influential than the students’ own capabilities as learners in the professional education process. The role of chance was most evident in the context of clinical education, where some students benefited from the mentoring of self-reflective clinical educators who modelled clinical reasoning and made reasoning an explicit part of their teaching and feedback. In arguing that clinical reasoning is such an integral and complex component of effective, capable practice, we contend that the availability and quality of opportunities for facilitation of clinical reasoning capability need to be guaranteed for all students. Such learning should be a core rather than chance component of the professional education journeys of all health professional students.
In this chapter we identify several ways in which capability in clinical reasoning can be facilitated during the professional education process. We consider opportunities for such learning within the professional socialization process, academic classroom and clinical education learning contexts. Such strategies could also be employed in other curricula.
Professional socialization is a complex learning process that occurs throughout professional entry education (Cant & Higgs 1999, Clouder 2003, Weidman et al 2001). Upon graduation, students have learned how to do physiotherapy, but more importantly they have become physiotherapists – they have constructed their professional identity. As part of their professional identity formation, physiotherapy graduates have developed an understanding of their new professional role and a vision of how they should act and interact within the healthcare system, within the profession, and with their clients.
We contend that students’ learning during their professional socialization, reflected in their construction of a professional identity, has direct implications for their clinical reasoning approach and capabilities as they enter the professional practice community. Graduates’ interpretations of who they are and who they should be in their professional roles directly relate to how they frame situations or identify problems to be solved, and how they think through and act upon decisions they make (Schön 1987, Wenger 1998). Within clinical reasoning all elements of practice are integrated and put into action, including identity, philosophy of practice, profession-specific technical skills, communication, collaboration, and ethics. Successful completion of the professional entry educational process culminates in the transformation of students to fully participating members of the professional community of practice (Lave & Wenger 1991, Wenger 1998). As Wenger (1998) stated, ‘such participation shapes not only what we do, but also who we are and how we interpret what we do’ (p. 4).
Key elements of capability are recognizable in the clinical reasoning of skilled physiotherapists, and best demonstrated in the clinical practice of skilled clinicians (Christensen 2007). Expert participants have been found to employ a collaborative approach in their clinical reasoning and to embody a patient-centred philosophy in their practice (Edwards et al 2004, Jensen et al 1999). In the USA, where Christensen’s (2007) research participants were located, the adoption of patient-centred approaches to practice is an explicit requirement within the published professional entry curricula guidelines. This is consistent with the philosophy adopted by the American Physical Therapy Association (2003) and the World Confederation for Physical Therapy (2004) and is an expected element of the professional socialization of new physiotherapists in America. However, in her research Christensen (2007) found that although the participants recognized the value of being collaborative and patient-centred in practice, this was not universally reflected in their practice. In particular, some participants’ ideas of their role as a physical therapist and the role of the patient were inconsistent with a patient-centred orientation to clinical reasoning. For example: ‘I think my role is … to just kind of use your knowledge and apply it to them. And their role is, I guess, to trust you and then to follow your directions’ (John).
In their clinical reasoning these students demonstrated beliefs and actions more consistent with therapist-centred approaches to practice, evidencing a belief that they were supposed to possess sufficient specialized physical therapist knowledge to independently reason through the problem, diagnose and prescribe to/for patients the proper plan of care (in contrast to collaborating with their patients in reasoning and decision making). On the other hand, some participants demonstrated views more consistent with a collaborative, patient-centred approach to reasoning in practice. One participant described his view as follows:
That’s why it’s so important for you to define their goals from the outset, so then you can adjust your way of dealing with this patient or include things or exclude things from the programme. … So it’s kind of like an interplay between they’re the ultimate decision maker, you teach them what to do, how to do it, help them do it, … and I think everyone is happy, hopefully, at the end. (Frank)