Validation of a Script Concordance Test to Measure Clinical Reasoning for Assistive Device Prescription
Purpose/Hypothesis: Clinical reasoning (CR) is “a nonlinear, recursive cognitive process in which the clinician synthesizes information collaboratively with the patient, caregivers, and the health care team in the context of the task and the setting.” Possessing excellent CR is imperative to providing efficient and individualized care from physical therapists (PTs), especially for effective assistive device (AD) prescription. The CDC reports that 6.5 million individuals use an AD to assist with their functional mobility. However, it is unknown how appropriate the AD is or whether ADs have been abandoned by patients. Currently, there are no validated measures of CR for PTs. A script concordance test (SCT) is designed to reflect the uncertainty in clinical practice and measures CR utilizing vignettes to reflect typical patients. The structure of a SCT differs from other types of summative tests. A SCT contains a series of vignettes followed by 3 questions based on each vignette. The unique question structure consists of 3 parts: first, a desired examination or intervention is presented; second, an additional piece of information is presented the student must use for CR and, upon which in part 3, the student judges whether or not the initial examination or intervention is still supported using a Likert scale. The purpose of this study was to develop and validate a SCT to measure CR in novice PTs during prescription of AD for those with traumatic brain injury (TBI) or cerebrovascular accident (CVA) within inpatient rehabilitation [skilled nursing facility (SNF)/inpatient rehabilitation facility (IRF)].
Number of Subjects: 20
Materials and Methods: A SCT containing 54 items nested within 18 vignettes was developed. Test items covered evaluation, treatment, and discharge phases of therapy in both inpatient rehab and home care settings, with a focus on patients with CVA or TBI. Items were based upon previous studies that described PT practice in inpatient rehabilitation and homecare. A convenience sample of experienced PTs with at least five years of experience, and currently working in the field of neurological or home care PT completed the test and gave feedback. Twenty-six were contacted, with 20 tests completed and returned, for a 76.9% response rate. Frequencies were used to describe the panel and to obtain the mode for each test question, which established the correct answers for future studies. Test reliability was determined using Cronbach’s alpha and G-coefficient, more appropriate for the SCT structure. The G-coefficient was also analyzed to determine the inter-rater reliability between experts. SPSS was used to analyze the data.
Results: The mean years in practice was 15.7 (7.0). There were 6 participants employed in SNFs, 12 in IRFs, and 9 in home care. The panel believed that the test reflected standard practice for inpatient rehab and for home care settings. Reliability results were acceptable at 0.732 and 0.70 for the Cronbach’s alpha and G-coefficient, respectively.
Conclusions: A SCT was validated to measure CR used during AD prescription in inpatient rehab settings and in home care. This test has acceptable internal consistency and panel inter-rater reliability. This test objectively measures CR and furthermore, may assist with training novice clinicians by measuring growth in CR over time.
Clinical Relevance: A SCT has been designed to measure clinical reasoning regarding the prescription of ADs in inpatient rehab and home care in patients with stroke and brain injury. A test like this could allow educators and senior PTs to objectively measure CR for students or novice PTs.