Clinical Reasoning Continuity - Bridging the Gap between Academic and Clinical Education
Purpose:
Even with the rapid growth of published studies investigating various aspects of clinical reasoning and clinical decision making over the past two decades, consistent, comprehensive, efficient, user-friendly methods to teach, learn and assess clinical reasoning evade rehabilitation professionals and students. The purpose of this poster presentation is to describe the development and implementation of an inter-professional clinical reasoning template in physical and occupational therapy clinical education. This template, the Rehabilitation Clinical Reasoning Tool (RCRT), has been shown to help student physical therapists organize and communicate their cognitive, psychomotor and affective clinical reasoning processes, and facilitate problem solving and metacognition. It is an efficient and comprehensive tool that facilitates both effective patient management and communication about clinical reasoning. This poster describes the expansion of the template to physical and occupational therapy faculty, clinical educators and students for application on clinical internships. Related literature, the RCRT, the process by which implementation will occur are described, and advancement of professional goals are discussed.
Clinical reasoning and clinical decision making (CDM) are identified within the Minimum Required Skills of Physical Therapist Graduates at Entry-Level as “indispensable for a new graduate physical therapist to perform on patients/clients in a competent and coordinated manner.” Several clinical reasoning/CDM models have been published in physical therapy (PT) literature over the past three decades including, but not limited to, the Hypothesis Oriented Algorithm (Rothstein and Echternach, 1986), the Rehabilitation Problem-Solving Model (Steiner, et al., 2002) and more recently the Systematic Clinical Reasoning in Physical Therapy (Baker, et al. 2017). Additionally, other articles in physical therapy publications compare problem solving processes between physical therapists and physicians as well as physical therapist experts to novices; describe reasoning/CDM specific to pediatrics, orthopedic manual therapy, and discharge planning, and clients’ behavior change; describe various clinical reasoning assessment tools; provide a literature summary via systematic review, and describe a concept analysis to better define clinical reasoning.
Occupational therapy (OT) publications have taken a similar trajectory to those in physical therapy. Several articles describing OT reasoning processes (Rogers and Masagatani, 1982), comparing occupational therapist reasoning to medical physician reasoning (Fleming, 1991), reporting effects of instructional strategies (Coker, 2010 and Henderson, et al., 2018), comparing novice versus expert OT practitioners (Unsworth, 2001), and producing a systematic review (Unsworth, 2016) appear in peer-reviewed publications.
Clinical reasoning/CDM models serve as an effective framework to organize cognitive processes during patient management. Dissemination of related study potentially facilitates consistent use of terminology and introduces effective instructional strategies to teach clinical reasoning. However, variability in the literature has been identified as a barrier to progress in this arena, and a discrepancy between academic and clinical education applications of clinical reasoning/CDM models/tools persists. Most physical and occupational therapy clinical instructors are unfamiliar with published models and struggle to both assess and teach students to reason in a comprehensive and efficient manner. This becomes especially relevant when clinical instructors must rate student clinical reasoning/CDM performance using common clinical education assessment tools and determine whether a student meets a passing threshold for the internship.
Methods/Description:
Teaching, learning and assessing comprehensive yet efficient clinical reasoning can be a significant challenge for PT and OT students and educators, both academic and clinical. In response to this challenge, an interprofessional clinical reasoning framework template, the Rehabilitation Clinical Reasoning Tool, was created to provide learners and educators with a well-defined structure within which to teach, learn, apply and communicate about clinical reasoning. This instructional design integrates patient management processes with the Biopsychosocial Model, uses familiar terminology, and is less abstract than previously published clinical reasoning algorithms.
The Rehabilitation Clinical Reasoning Tool consists of six clinical reasoning categories referred to as “lines of thought”. They include Psychosocial, Examination, Diagnosis, Prognosis, Intervention and Outcomes. The Psychosocial category represents narrative, interactive, collaborative, intuitive and ethical types of reasoning as well as contextual factors relevant to patient management; Examination and Intervention represent procedural reasoning as well as teaching as reasoning; Diagnosis represents diagnostic reasoning; and Prognosis represents predictive reasoning. The template outlining types of reasoning across six lines of thought captures the interrelated, nonlinear and iterative nature of reasoning processes in rehabilitation. The terms, when presented as an acronym (P/SEDPIO), create a memorable mnemonic with familiar terms which aids learner recall and subsequent “buy in”.
This model has been used in physical therapist academic education to facilitate recall of clinical reasoning categories, communication of clinical reasoning processes in an organized fashion, and assessment of clinical reasoning skills. It provides an effective framework to facilitate recall of the cognitive, affective and psychomotor reasoning processes used during patient/client management and is appropriate for both novice students and experienced practitioners. It is more efficient and perceived to be less complex than several previously published clinical reasoning models that have not been widely applied in clinical practice or clinical education.
Results/Outcomes:
A barrier to generalized use has been the lack of familiarity in clinical institutions. Thus, dissemination to the clinical community was deemed essential for integrated student learning. The initial step in this process was to introduce the model and propose a dissemination plan to the physical therapy Site Coordinator of Clinical Education at a large regional healthcare network serving as clinical partner. Second, the RCRT was introduced to the academic institution Occupational Therapy Academic Fieldwork Coordinator with discussion related to value and dissemination to the OT student body, faculty and clinical education site coordinator. Third, the PT and OT academic faculty and site coordinators proposed the plan to rehabilitation administration at a quarterly meeting between the academic institution rehabilitation faculty and the clinical partner rehabilitation administrators. The RCRT was well-received at every level, and all constituents have agreed to participate in an educational process for Occupational Therapy students and faculty as well as clinical partner rehabilitation staff therapists. This will result in familiarity with and competent use of the RCRT.
Conclusions/Relevance to the conference theme:
Construct development in learners requires effective conceptual organization, and this instructional model seems to provide a useful architectural framework to organize the clinical reasoning processes used during patient management. The Rehabilitation Clinical Reasoning Tool has been used in physical therapy entry-level education by the principle author for several years to enhance teaching, learning, and assessment of the often complex and ambiguous clinical reasoning process. To date, it has been well-received by students and faculty as an effective template to 1) facilitate the development and assessment of clinical reasoning skills, and 2) enhance clinical reasoning communication between students and academic faculty. It is comprehensive, efficient and functional thereby promoting sound clinical reasoning designed to ultimately improve the quality of patient care.
This poster describes an innovative model/template and the path to successful dissemination in collaboration with an Occupational Therapy program housed in the same institution and a large regional healthcare network. Ultimately, this interprofessional initiative links entry-level academic programs and faculty with network rehabilitation administration and, most purposefully, with PT and OT clinical instructors. This link helps to bridge the gap between academic and clinical education and foster continuity in rehabilitation education as it pertains to clinical reasoning teaching, learning, assessment and communication. Analysis following implementation may identify new avenues for additional interprofessional collaborations and discoveries to further enhance practitioner and network process as we strive to advance care for our patients.