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)
These findings have direct implications for ways in which to increase the likelihood of facilitating development of capability in clinical reasoning within the professional socialization process, including the way this capability is influenced by the practitioner’s practice model (e.g. patient-centred care). Educators can help students understand that the whole of the learning experience that is becoming a professional – a physiotherapist – is the bigger context within which the learning of how to be a physiotherapist (part) and of how to do physiotherapy (part) are interrelated and inseparable from each other. This is consistent with the suggestions by Bowden & Marton (1998) in the educational literature that the type of learning linked to being and becoming capable involves developing ways of experiencing and understanding phenomena (creating meaning) through a process of discernment of the ‘parts and the whole, aspects and relations’ (p. 33).
By making overt the hermeneutic nature of the learning involved in their professional development, educators can also facilitate development of some of the thinking and learning skills that we have proposed are key dimensions of capability in clinical reasoning (Christensen 2007). According to Davis & Sumara (2006, p. 167), critical reflection about one’s pre-existing perceptions of reality and development of new perspectives through incorporation of new understandings (which is characteristic of hermeneutic inquiry) are ‘deeply compatible’ with complexity thinking.
We propose that capability in clinical reasoning can be facilitated by education which pays overt attention to the relationships between key elements of who we are as physiotherapists and how this can and should be reflected in our clinical reasoning and associated actions – congruent with how we think and what we do in practice. One key to guiding students’ learning toward capability is the development of critical thinking skills and promoting students’ pursuit of critical self-reflection on their reasoning and decision making. In particular, students should be encouraged to reflect on any inconsistencies between their professional identities, their reasoning and their clinical actions.
Professional entry education of physiotherapists consists of two distinct components: that conducted in the academic classroom setting and that conducted in the clinical education setting. The clinical education context provides students with the opportunity to experience and practise putting into action what they have learned in the academic component of their education. It also provides unique and invaluable experiential learning opportunities where students’ classroom knowledge is transformed and enhanced through experience, and their construction of practice knowledge begins (Higgs et al 2004). Both these learning contexts provide opportunities to reinforce, integrate and expand what is learned in the other, preparing students for real-world practice.
Christensen’s research (2007), in contrast, showed that many student physical therapists in the programmes studied experienced a lack of coherence between the academic and clinical educational settings in relation to the teaching and learning of clinical reasoning. She found that the development of clinical reasoning capability can be facilitated by the creation of more overt integration of the teaching and learning occurring in these two learning settings.
When considering how to facilitate this integration we find particular relevance in Wenger’s (1998) discussion of the ways in which communities of practice develop and socialize new members to negotiate meaning from experiences in practice. According to Wenger, practice involves the negotiation of meaning through the interaction of two constituent processes, reification and participation. We discuss below examples of how a process of reification of and participation in clinical reasoning in both educational settings can facilitate the development of clinical reasoning capability in student physiotherapists.
For participants in Christensen’s study (2007), little of their academic programme overtly dealt with understanding clinical reasoning as a means of integrating different areas of learning into their overall approach to decision making in practice. For example, one participant explained:
We did discuss different approaches to psychological aspects, emotional issues, worrying … about attending to people’s other needs and potential referrals you should make, but I don’t think it was ever really discussed in terms of clinical reasoning, it was just like this is something else to put together. And for me personally, I was thinking physical stuff would be clinical reasoning, and then the emotional, touchy feely stuff would be, … [separate]. I just never really put it together in the same boat until now. (Robin)
Reification refers to the process whereby a community of practice gives form to concepts and experiences central to practice in order to facilitate the shaping of experience by members of a practice community; it results in ‘focusing our attention in a particular way and enabling new kinds of understanding’ (Wenger 1998, p. 60). Reification may involve the production of ‘abstractions, tools, symbols, stories, terms and concepts that reify something of that practice in a congealed form’ (Wenger 1998, p. 59). We contend that clinical reasoning, a complex abstract and practice phenomenon, is a key component of practice that can and should be reified in the academic classroom setting. Such overt reification can foster students’ paying attention to and learning to communicate clinical reasoning; it has the potential to facilitate experiential learning throughout the whole professional entry education process, but especially during clinical education.
Definitions and models of clinical reasoning can assist this process of reification of clinical reasoning in the academic classroom context. The explicit exploration of the ways in which clinical reasoning is described in theoretical and research-derived models can allow educators to ‘create points of focus around which the negotiation of meaning becomes organized’ (Wenger 1998, p. 58). Through this process students learn to cope with the task of making sense of the overwhelming amounts of information that they will face in practice in the context of collaborating with each individual patient. This is consistent with the view of education for capability put forth by Bowden & Marton (1998), who emphasized that ‘it is important to make ways of seeing (e.g. making meaning in the context of clinical practice) visible to students’ (p. 40).
This finding suggests that overt attention should be directed towards the facilitation of students’ understanding of clinical reasoning in general and to understanding the thinking and motivation of all the participants (clinician, patient/client, caregivers, other healthcare team members) in the clinical decision-making process. The students need to understand different clinical reasoning strategies, dialectical thinking, metacognition/reflection and critical thinking processes and the impact of a range of contextual factors (e.g. practice setting, time constraints, economic resources) on clinical reasoning. To achieve these outcomes requires an educational focus on the facilitation of students’ understanding of how all of these parts influence and are influenced by each other within the whole of the clinical reasoning process.
As one example, students could explore the model of clinical reasoning as a dialectical process presented by Edwards and colleagues (Edwards et al 2004, Edwards & Jones 2007). We view dialectical thinking as an important dimension of clinical reasoning capability and as an inherent aspect of capable expert practice. Educators can explore with their students how dialectical thinking could be realized in action, and can facilitate students’ attempts to reason through a variety of mock practice scenarios in ways consistent with these models.
Educators can also discuss with their students the connection between clinical reasoning and learning from practice. They can overtly explore opportunities for engaging in metacognition and for application of critical thinking skills in reflecting on their own reasoning and in providing critical feedback on the reasoning of their peers.
In these examples of application of early reified understandings to practice scenarios, it becomes clear that reification of clinical reasoning should not stand alone but requires participation in actual practice-based decision making, to allow students to translate and construct for themselves a deeper understanding of clinical reasoning, and to begin to ‘renegotiate its meaning in a new context’ (Wenger 1998, p. 68). Although participation in the academic classroom setting is necessarily limited in that it is not a true practice context, it can be likened to the process by which newcomers are gradually brought into practice communities through limited, more peripheral forms of participation (Lave & Wenger 1991).
By overtly facilitating students’ understanding and practice of reflective, critical and dialectical thinking skills within clinical reasoning in the academic setting, educators can also guide students towards development of the thinking and learning skills needed for capable reasoning in the clinical education setting. By laying a theoretical foundation through reification of clinical reasoning, and then facilitating a form of participation with clinical reasoning through simulated practice activities in the classroom setting, educators can provide students with opportunities to develop their understanding of the complex nature of clinical reasoning and its link to other components of their education (e.g. theoretical and research knowledge, practical skills, communication skills, professional identity). This can allow students to practise elements of doing physiotherapy and being physiotherapists in a setting that is far more predictable and less complex than the clinical education setting.
We propose that by facilitating an overt awareness of clinical reasoning and by providing opportunities for controlled practice with complex models of clinical reasoning in the academic classroom setting, educators can explicitly guide students away from any tendencies toward overly reductionistic, linear, or rigid ways of perceiving and thinking in practice. Such rigid ways of framing situations are not congruent with the adaptive, flexible, multifaceted approaches to collaborative patient-centred reasoning and practice demonstrated by expert physiotherapists (Edwards & Jones 2007, Jensen et al 1999). Acknowledging that ‘humans must differentiate, interpret, draw analogies, filter, discard, and generalize in order to deal with the vast amounts of information that confront them in every moment’ (Davis & Sumara 2006, p. 26) means that educators should foster in students an approach to clinical reasoning that achieves an appropriate balance in the perception and weighting of the relevant factors within a larger complexity perspective (Stephenson 2004).
Complexity thinking prompts the examination of relationships ‘between and among different layers of organization, any of which might be properly identified as complex and all of which influence one another (in both enabling and constraining ways)’ (Davis & Sumara 2006, p. 26). We see the development of complexity thinking, which we propose as a key dimension of clinical reasoning capability, to be a desirable focus of teaching and learning in professional entry education. ‘Complexity thinking helps us actually take on the work of trying to understand things while we are a part of the things we are trying to understand’ (Davis & Sumara 2006, p. 16). This is precisely the nature of the work that students must learn to accept if they are to become capable clinical reasoners in the context of collaborative client-centred practice.
Wenger (1998) argued strongly that participation and reification are both intrinsic and complementary to each other in the negotiation of meaning. Participation is the process by which reification is produced and interpreted, and reification enables participants in a community of practice to communicate about and coordinate their perspectives and meanings derived from experiences. According to Wenger (1998), one cannot exist without the other, and their duality is essential to the type of learning newcomers must achieve in order to become full participating members of a community of practice. Through participation, the learning of reified structures and practices is put into action, and through critical reflection they become open to revision and expansion as learners go beyond their initial understandings.
The professional entry education system of physiotherapists (similar to the education systems of all healthcare professions) relies in great part on situated clinical education learning experiences to provide the context and opportunity for students to become novice professional practitioners. As discussed earlier, research participants in Christensen’s (2007) study experienced varying opportunities for facilitation of participation in and reflection on clinical reasoning during their clinical education experiences. Overall, the participants reported that the majority of their learning related to clinical reasoning occurred during clinical education, but that the availability and quality of opportunities for facilitation in the clinic were greatly influenced by the characteristics of assigned clinical educators. Clinical educators varied greatly in their awareness of and ability to facilitate clinical reasoning and the thinking and learning skills (reflection, critical thinking, dialectical thinking and complexity thinking) which our research identified as intimately involved in its capable performance.
One participant described the situation as follows:
And if you haven’t one good CI [clinical instructor], then you really haven’t learned at all, … we’re getting a great education, but if you have been just with crummy CIs this entire time, you have no chance of really applying it and using your knowledge, and so … you pretty much have wasted this education if you haven’t been able to talk it out with someone who really knows how to help you learn and motivate you to learn. I think who you end up becoming as a PT is largely based on who you’ve had in your past experiences. I think it’s really important that everyone gets a really good clinical experience at some point, …’cause you’ll get bad luck, sometimes people end up with some terrible CIs, so I just think it’s really … it’s really important that we all get a chance to be somewhere good. (Diane)
We propose that within the clinical education setting, capability in clinical reasoning can be facilitated though interaction with skilled clinical educators who are aware of the reified conceptions of clinical reasoning that students bring from the academic classroom setting, and who understand and are skilled in ways of guiding students toward the construction of their own understanding of clinical reasoning through participation and critical reflection in the real world. To achieve this, clinical and academic classroom educators must communicate and coordinate their efforts, overcoming the barriers inherent in being physically and pedagogically separated. A strengthening of the links between educators in the academic and clinical education settings is necessary in order for all students to be facilitated in developing capability in clinical reasoning throughout the whole of their professional education process. Wenger (1998) argued for a balanced pedagogical approach to teaching and learning of complex knowledge: ‘An excessive emphasis on formalism without corresponding levels of participation, or conversely a neglect of explanations and formal structure, can easily result in an experience of meaninglessness’ (p. 67).
For educators aiming to facilitate clinical reasoning capability in their students, this learning process might best be viewed as the development of ‘ever more sophisticated ways of interpreting experience. So understood, the most critical aspect of a teacher’s role is not provision of information, but participation with learners in the development of strategies to interpret that information’ (Davis et al 2000, p. 131). The clinical reasoning of healthcare professionals can be regarded as a complex expression of their negotiation of meaning in practice – their strategy for interpreting and learning from clinical experiences. The intentional provision and facilitation of learning opportunities that guide students toward the development of capability in clinical reasoning is certainly a very important way in which educators can contribute to improving professional entry educational outcomes.
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