Ryan, Jennifer M.; Gorman, Sharon L.
In 2004, Edwards et al1 described a model of clinical reasoning in physical therapy to address more than the reasoning about the patient's problems and subsequent intervention, and was more inclusive of all aspects of patient care. More familiar to practicing therapists is the diagnostic reasoning portion of this model, where various clinical reasoning strategies are directed toward the identification of the patient's diagnosis, prognosis, and interventions. Less familiar may be what else is happening concurrently—the therapist engaging in a line of narrative reasoning whose outcomes are directed at the therapist's communications with all involved parties.2 Six primary clinical reasoning strategies are used as needed for both the diagnostic and narrative reasoning processes (Table 1).2 Most familiar to practicing therapists are procedural reasoning, reasoning about teaching, and predictive reasoning. Reasoning strategies that may not be as familiar, but are likely employed often in daily practice, include interactive reasoning, collaborative reasoning, and ethical reasoning. In acute care practice, not only do all of these clinical reasoning strategies assist the therapist in achieving patient outcomes, but oftentimes because of the interprofessional aspect of practice, they are used when working with other members of the health care team. This adds a layer of challenge to the patient/provider milieu and can distinctly influence the communication among the members of the health care team.3 By understanding the choices the therapist is making regarding the use of these six clinical reasoning strategies and their influence over both diagnostic and narrative reasoning, therapists can enhance their interactions with the interprofessional team while also allowing for more self-reflection after interactions, which has been shown to be an important and necessary step toward improving practice.4
How important to acute care practice is the ability of the therapist to use these strategies? Specifically related to the diagnostic reasoning process, Masley et al5 identified an area of acute care practice called “collection and analysis of medical information”5(p 910) although the acute care practice analysis had multiple items grouped under the heading “pathology and pathophysiology.”6(p 1463) Acute care practice uses physiology and physiologic monitoring as its backbone. The ability of the therapist to assess the risk of untoward events brought on by exercise, activity, and even rest, coupled with the need to prevent comorbidities while acutely ill is a requirement of skilled acute care practice.6 Likewise is titration of exercise or activity in light of known pathophysiology to facilitate improvement in function that is continually adjusted in relation to the dynamic, ongoing physiologic responses of a patient a skill needed for successful acute care physical therapy intervention.7
In Masley et al's qualitative study of acute care practice, two of the four primary areas used in decision making for patient management include “communication to provide information” and “communication to gain information.”5(p 910) Similarly, the acute care practice analysis identified distinct areas of acute care practice aimed at collaborating with both patients and health care providers as well as educating patients and health care providers.6 Of note, the acute care practice analysis identified that acute care physical therapists needed to be skilled at “participating in activities ... in order to expand, improve, or define practice or awareness of acute care physical therapy”6(p 1463) and to advocate on their patients' behalf to the medical team to ensure appropriate care and follow-up. These findings support the need for acute care physical therapists to be skilled at narrative reasoning strategies and cognizant of the clinical reasoning that goes into the choices they make surrounding their communication with patients, families, and other members of the health care team.
Although clinical reasoning is needed for the therapist to make determination of important factors related to patient/client management, the therapist's clinical reasoning is often not automatically understood by the patient, and the patient's family, and other members of the health care team, and therefore needs to be clearly communicated. Many health care professionals are trained to use the SBAR (situation, background, assessment, recommendation) method promoted by the Institute for Healthcare Improvement as a communication technique for interprofessional situational briefs shown to increase patient safety.8 This method allows providers to focus on necessary details in an organized format concluding with recommendations or action steps to be taken on the basis of the knowledge sharing and collaboration inherent in the model. Another communication method, motivational interviewing is a counseling technique aimed at improving motivation and adherence to behavior change.9 Although frequently employed with patients, motivational interviewing techniques can be used in interprofessional communications where the purpose is not only to provide information but to have that information result in behavior change, such as working with physicians and physician extenders to provide appropriate physical therapy referrals or with nursing to implement more active mobilization of patients. Jette et al10 described acute care patient management and observed acute care therapists working. Across the three sites included in this study, communication was a frequent occurrence, especially with other members of the health care team (Table 2). This study concluded that “it might be expected that communication is essential in a setting in which patients' medical status may change from moment to moment, where patients may be moved from one level of care to another quite rapidly, and where length of stay is short.”10(p1169) A brief summary of these two particular communication methods is provided in Table 3. Physical therapists should consider when and how they employ specific communication techniques to achieve successful patient- and interprofessional-specific outcomes with specific consideration for the short turnaround time between understanding of a problem and determination of a solution in acute care settings.
Like all aspects of evidence-based practice, no cookbook exists. No “how to” document for people to follow while interacting with other medical professionals is available. Successful interprofessional communication is an ongoing dialogue that should be patient focused and brings forward all of the strengths of the members of the team who collaboratively address all of the needs of the patient while keeping the patient at the center of the conversation. Although providing extensive review of these communication techniques or detailed examination of clinical reasoning strategies is beyond the scope of this article, to better illustrate the complexities of interprofessional communication in the acute care setting, four case examples will illustrate some of the opportunities that therapists have to maximize the positive impact that a therapist can have on a patient outcome (Table 4).11,12 These cases are representative of actual clinical scenarios and allow demonstration of a variety of clinical reasoning strategies and their use. All patients in the cases have been de-identified and adapted to protect patient confidentiality.
TABLE 4-a. Case Exam...Image Tools
CASE 1: FANNIE M.
TABLE 4-b. Case Exam...Image Tools
Fannie M. is a 65-year-old woman with a history of stage IV endometrial cancer, hypertension, and osteoarthritis. Physical therapy was consulted for evaluation and treatment on day 10 of her hospital stay, which was also her projected day of discharge. Upon chart review the resident's daily progress notes stated, “Alk Phos levels elevated—bony mets likely.” No record of any recent bone scan, positron emission tomography scan, computerized tomography, or magnetic resonance imaging of any bony structures was found during the review of her health record during this admission. This lack of data in the chart to define the risks related to the noted laboratory results raised a concern, and the referring service was paged to clarify. Upon speaking with the referring service resident the therapist was asked to, “See her so that she could go home.”
For this case, we will start with reviewing issues related to her risk for bony metastasis using diagnostic reasoning. Mention of alkaline phosphatase, abbreviated “Alk Phos” in the resident's note, indicates a probability for bony metastases, which would normally lead to a further investigation with imaging. The laboratory value cannot definitively determine the type, location, or extent of bony involvement. Markers of bone resorption have high specificity but very low sensitivity because the laboratory test measures all isoenzymes of alkaline phosphatase, not just those related to bones.13 Elevation could mean liver, bone, or other organ dysfunction.14 Bone-specific alkaline phosphatase is a biochemical marker of osteoblast activity along with osteocalcin and type I procollagen C-propeptide, but this more specific value was not included in the patient's laboratory test results.15
With respect to multiple areas of diagnostic reasoning, the therapist took into consideration Fannie's type of cancer and her probability for the type of bony metastases that she may likely have, so the medicine service was contacted to determine whether previous imaging from an outside hospital had occurred or was obtained. The medical resident stated that they had reviewed Fannie's prior images that revealed that she had bony metastases “all over her pelvis.” The implied bony impairment as a result of the number of metastases alone would indicate a probable need to limit weight bearing. The information passed to physical therapy related to the available imaging report did not clearly state a location more specific to weight-bearing concerns (ie, acetabulum vs iliac crest, cortical involvement, or size).16
The most concerning untoward event for a person with numerous bony metastases, like Fannie had, is referred to as a skeletal-related event.16 If Fannie's metastases in her pelvis were to lead to a skeletal-related event, the negative sequelae would include pain and pathological fractures, with subsequent changes in mobility frequency and independence being likely.16 Most patients with bony metastases have evidence of both abnormal bone resorption and bone formation. Hence, both osteoblastic and osteoclastic lesions present the risk of pathological fractures.17
Fannie M.'s primary service was a medicine service, and orthopedics was not consulted during this hospitalization. The medical resident was unaware that the tumors observed on the imaging studies could impact the patient's bony integrity, and increase the risk of fracture if weight bearing were not limited. Using the SBAR format, the therapist provided enough “situation” and “background” physiology information when discussing with the resident.8 In the “assessment” portion of this communication technique, the physical therapist communicated the probability that the patient would encounter many movements in her activities of daily living that are anisotropic in nature, with variable direction torsion, compression, and weight shifting during even simple tasks, that then put the patient at a greater risk of fracture.18–20 The therapist's “recommendation” consisted of confirming, in light of the bony risks, that the resident agreed that limiting weight bearing would benefit the patient. This is a prime example of reasoning about education, in this case the education of the physician on the medicine service, and using the SBAR technique to discuss with another health care provider.
Predictive reasoning also factored in this case; the patient's cancer put her at an increased risk of venous thromboembolism; therefore, exercise and mobility was advocated to reduce her risk of developing a blood clot.21 The method, intensity, and duration were dictated by her bony risks, her energy impairment because of her primary disease and prolonged hospitalization, and her prognosis and need to prioritize her activity in relation to her attention to her family and friends.21 Other concerns were to use daily activity to reduce her risk of other cardiovascular and pulmonary comorbidities of pneumonia and impaired endurance.21
The treating physical therapist initiated the physical therapy examination and received the patient dressed in her street clothes and awaiting transportation to discharge home. The patient's first comment, before hello, was, “Don't make me stay here.” Fannie's family was present and very supportive of the physical therapist's role and demonstrated an understanding of the need to practice mobility consistent with the intensity of challenge necessary to enter their second-floor apartment. The therapist needed to engage in interactive reasoning to explore Fannie's view of physical therapy being a barrier to her impending discharge home, and used motivational interviewing techniques successfully to obtain this information.9 By approaching both Fannie and her family with the planned activities, the physical therapist was able to address Fannie's unique need to learn attenuated mobility in the timeframe that she desired. The unique knowledge, skills, and abilities of a physical therapist consider the multisystem impact of Fannie's disease process on her functional level to design a safe discharge plan.
The patient performed a sit-to-stand transfer independently with family supervision. Fannie was educated in gait training with a rolling walker with weight bearing as tolerated precautions on level surfaces. She was fatigued after 60 ft and required a sitting rest break before progressing to gait training on stairs with family assistance and using one railing. The physical therapist also educated Fannie and her family about her bony risks and the need to use an assistive device at all times to reduce pain and facilitate movement. These interventions demonstrate the use of procedural clinical reasoning (assistive device prescription and training) and reasoning about teaching (educating the patient and family about her risk). Fannie was able to not only meet her goal of returning home that day, but also, through interprofessional collaboration, do so in a safe manner, minimizing her risks of immobility, skeletal-related event, and falls.
CASE 2: JACOB S.
Jacob S. is a 54-year-old man, status postmyocardial infarction with a fall and subsequent coronary artery bypass grafting of two vessels, who was seen by physical therapist on postoperative day 2. He has a medical history of type 2 diabetes mellitus and hypertension. Jacob's chart review demonstrated a usual postoperative course. He was now on the step-down unit after leaving the intensive care unit on the afternoon of postoperative day 1. Upon arriving to the patient's room that morning, a conversation between the patient and nursing staff was overheard. The patient was refusing his morning cardiac medications because he “did not have a headache or chest pain.” Nursing staff educated the patient on the need for blood pressure (BP) control and cholesterol management postoperatively, but the patient continued to refuse all medications except his Vicodin. The medications he refused included antihypertensives (beta-blocker and diuretic), Plavix, and Glucophage. The patient was actively involved in his plan of care, and demonstrated his wish to be in charge of his treatment. The therapist at this point was worried that the patient may not, however, be making a truly informed decision with regard to refusing his medications.
The patient agreed to the physical therapy initial examination, stating that he was concerned about how the pain from his fall would affect his movement. The patient's vital signs at rest were BP 132/74, heart rate (HR) 92, respiratory rate (RR) 12; no symptoms. After a 40-ft walk on a level surface without an assistive device, his vitals were BP 164/86, HR 114, RR 19; symptoms of dyspnea on exertion, fatigue, but no increase in pain.
The patient had no symptoms at rest, but activity brought on cardiac changes, as noted by his signs and symptoms, which limited his mobility and activity level. The therapist believed that taking the medications prescribed to him could improve his exercise response. The therapist postulated that by not taking his medication, Jacob would not be able to maximize his activity and over time may become increasingly deconditioned. The only way to know whether his prescribed medications are adequately dosed to support his progressive activity would be to measure his vital sign and symptom response with progressive activity after taking the medications.
Predictive clinical reasoning used by the therapist initially focused on the patient's vital sign response and symptom presentation with limited activity (walking 40 ft), which indicated that he did not tolerate the activity well and that he would not progress well after discharge without medicinal support. The nurse and the physical therapist conferred about the postoperative concerns of vascular graft integrity, myocardial microcirculatory need for diastole, and the physical therapist illustrated how Jacob's present state was far from what he would need to be able to accomplish, even for household tasks, upon discharge. Microvascular alterations postcoronary artery bypass grafting are characterized by a marked heterogeneity of perfusion reflected by the decreased proportion of perfused small vessels.22 Similar to patients who are septic, the alterations are independent of global hemodynamic variables.22 Distribution of perfusion is more critical for tissue oxygenation than total blood flow to the area because heterogeneity of perfusion is more poorly tolerated than a homogeneous decrease in organ perfusion.12 The therapist used collaborative reasoning coupled with reasoning about education using SBAR technique with the nurse, with both agreeing to educate the patient together. The nurse and the physical therapist used motivational interviewing techniques, and learning that the patient was highly motivated to return home and progress his activity tolerance, educated the patient on the need to adhere to his medication regimen and that these medicines were not just for symptom management. The patient agreed to take his cardiac and other medication as prescribed. Collaborative reasoning is of utmost importance to work toward adherence of patients with their recommended interventions. In this case, the therapist reviewed medical reasons for the medication postoperatively with nursing, confirmed the patient's goal of returning home and increasing activity through motivational interviewing, and both collaborated to have the patient take his medications.
The physical therapist returned 1 hour after the patient took his medication, and the patient's vital signs at rest were BP 122/70, HR 78, and RR 12. Jacob was able to walk 200 ft on a level surface independently without a device. He ascended and descended 13 steps using one railing without a rest break. The patient's postexercise vitals were BP 128/67, HR 82, and RR 15—all with no symptoms of dyspnea. The patient was educated on performance of frequent short bouts of activity, performed within the limits of dyspnea and timed after taking his medication. Because of the collaboration with the patient earlier on the need for his medications, the patient understood the need for his medication before activity, and stated he would be adherent with this plan. The physical therapist shared these results with nursing, as the nurse expressed interest in the outcome of their joint educational collaboration with the patient, in itself another level of motivational interviewing technique aimed at helping the nurse expand her capabilities in patient education specific to medication effects on activity.
CASE 3: MARY J.
Mary J., a 69-year-old woman, was admitted with a fall because of changes in her lower extremity strength and proprioception status postoutpatient cervical epidural steroid injection (ESI) 3 days before admission. Upon further review of the chart, Mary's admission laboratory values were noted as follows: basic metabolic panel K 4.0 mEq/L (3.4-5.3 mEq/L); Na 129 mEq/L (137-147 mEq/L); HCO3 24 mmol/L (22-26 mmol/L); Cl 105 mmol/L (99-108 mmol/L); blood urea nitrogen 17 mg/dL (8-21 mg/dL); Cr 1.2 mg/dL (0.5-1.1 mg/dL).
Interpretation of Mary's laboratory values demonstrates diagnostic reasoning. The laboratory values' reference ranges are based upon valid and reliable research that unfortunately have no direct relation to exercise and activity.23 To perform a randomized control trial on the effects of sodium levels on exercise tolerance, the design would require that a normonatremic control group, a hyponatremic group, and a hypernatremic group each be exercised and then collect the data on their responses. Ethically, this research cannot be done because of the known neurological risks when a person's sodium level is outside the reference range; therefore, we have to deduce our answer. We know enough about hyper- and hyponatremia to start to define risks, but we do not know enough to have strict rules. We should consider existing research in determining a safe and progressive exercise program for Mary, but not assume that she should avoid all exercise because her sodium reading on her basic metabolic panel demonstrates that her sodium level is outside the reference range.24 In addition, no published critical range for sodium is available that would indicate severe risk of an adverse event due to exercise when the value is outside the critical range. Critical values do exist for the purpose of communication from the laboratory to the primary service to augment treatments to correct these values more aggressively than when they are outside the reference range, above or below, because of known changes in morbidity and mortality. Again, the role of exercise is not clearly defined here either.24
Rather, when you consider the common signs and symptoms seen with sodium imbalances, the therapist uses those commonly seen signs and symptoms to prescribe the intensity and duration of Mary's exercise/activity program. Hyponatremia, usually defined as sodium less than 136 mmol/L (always look at the reference range used by the laboratory that drew the sample from your patient, which can differ on the basis of the process used), exhibits with anorexia, impaired taste, muscle cramps, headache, lethargy, and nausea and vomiting. According to the Merck Manual,25 clinical manifestations are primarily in the neurological system (because of an osmotic shift of water into brain cells causing edema while the skull sets an upper limit on the amount of allowable swelling, unlike the skin of an extremity; therefore, the brain is the organ most sensitive to changes in sodium), especially in acute hyponatremia, and include headache, confusion, and stupor, seizures, and coma. The potential impact of Mary's hyponatremia on her function should be considered when determining her goals and discharge disposition recommendations. If the patient's present functional mobility demonstrates decreased independence from her baseline, this will likely improve as the medical treatments correct her sodium levels as they approach the normal range.
This situation speaks to how the reference ranges are guideposts, rather than data that blindly determine a decision, and may differ from critical values, which may indicate much more caution because of the increased risks. Obviously many factors should be considered when deciding when to see the patient and when to hold physical therapy. Mary was less neurologically sensitive to hyponatremia than some patients. The research can be used to assume that some potential impact exists; however, when considering the whole patient, the impact of the ion imbalance on the patient's ability to perform basic physiologic functions is key.24 Undertreating a patient on the basis of a laboratory value (especially an out-of-reference range value vs a critical value) can be detrimental to a patient who will remain on bed rest, who could have otherwise participated on some level to address mobility. This is a potential ethical issue for the therapist related to underutilization of therapy for the patient, and ethical reasoning using knowledge of pathophysiology and exercise response weighed against the risks imposed by unnecessary bed rest and immobility needs to be explored. The data gained from a comprehensive examination of Mary's physical state and cognitive ability to participate in progressive mobility are what helped the therapist make the decision on when and how to progress the patient.
Knowing that Mary had a fall and known neurological changes on her initial examination after her ESI, and now may have neurological limits because of her hyponatremia, she required balance testing to determine her fall risk. The patient was tested with the Modified Berg Balance Test and scored a 26 out of 28.26 Testing then progressed to performance of the Modified Dynamic Gait Index using a rolling walker, where Mary's score was limited only by her use of an assistive device.27 The patient was then tested again using handhold assistance to determine when and where she required physical assistance to manage her balance, and had an unchanged score of 8 out of 12. On the basis of these results, the therapist had Mary use a straight cane in the last phase of testing and the patient again scored an 8 because of her use of an assistive device, but the therapist noted no loss of balance or need for external assistance beyond the single-point cane during physical challenges. This sequence demonstrates the therapist's procedural reasoning.
The patient's nursing assistant, who was also a nursing student, encountered the patient and the therapist during balance testing and mentioned that he was happy to see her walking and that he was “just about to go and get her walking himself.” The therapist later spoke with the nursing assistant using the SBAR technique and aspects of motivational interviewing. Education was provided to him specifically about “background” and “assessment” of the physical therapist—all of the testing that occurred before ambulating in the hall, as well as the gait training with a new assistive device, the single-point cane, that occurred. This was to help him to differentiate when a patient needs physical therapy specifically before walking in the hall. Motivational interviewing revealed that, as a nursing student, he wanted to learn how to better care for patients with potential balance problems, rather than just a need to maintain their mobility, and related to his use of this information when encountering similar patients to request physical therapy referrals appropriately. This communication with the nursing assistant demonstrates the therapists' use of both interactive reasoning, through the timing and physical location of the interaction, and reasoning about teaching, and used both SBAR and motivational interviewing techniques, specifically when and how to educate the nursing assistant, and the future nurse, about these issues.
CASE 4: LISA T.
Lisa T. was a 64-year-old woman, status postexternal fixator placement for a comminuted right lower extremity tibia and fibula fracture. She had a recent history of a motor vehicle crash and had waited 4 weeks for surgery because of edema. During this time Lisa functioned at a wheelchair level for locomotion and was non-weight bearing on her right lower extremity. Initial activity on postoperative day 3 was gait training with non–weight-bearing precautions on her right lower extremity with a rolling walker. Lisa was able to ambulate 10 ft with a wheelchair following her for safety, and she stopped because of fatigue and subsequent reduced clearance of her left lower extremity. Of note, she walked 10 ft once on the day of evaluation, 10 ft twice on postoperative day 2, and now on postoperative day 3 demonstrated no apparent progress. At this point, activities and interventions for Lisa were focused on transfers, assuming she would start at a wheelchair level. Review of her medical record and information from the health care team's morning huddle indicated that the patient was scheduled to be discharged home on postoperative day 3, if cleared by the physical therapist.
In designing the setup of the transfer training for Lisa, she was asked to indicate when the mat table height was similar to her bed height at home while the therapist elevated the bed. Lisa's bed was exceptionally high, and safely transferring and maintaining her non–weight-bearing precautions were found to be too challenging for her. Lisa then stated that she would opt to sleep on a chaise lounge lawn chair in her living room. She stated that her husband had used this setup in the past and it worked well for him. The therapist reviewed that the hardware of the external fixator would likely need better support than a lawn chair and that entering and exiting the low chair while maintaining her non–weight-bearing precautions on the right leg would require a more stable surface than the chaise could offer. Using motivational interviewing techniques throughout the conversation, the therapist noted that the patient was relatively slow to respond and sometimes very limited in her answer depth or quality. Questions regarding her mental status and ability to care for herself were considered by the therapist, because Lisa may have had a residual deficit in her cognitive function from her motor vehicle accident, and the therapist also had concerns about how Lisa's pain medications may impact her cognition and limit her safety postdischarge. After two attempts at the bed to chair transfer were completed with moderate assistance, the patient was allowed to rest. The patient sat in the wheelchair for 15 minutes while the therapist worked with another patient. Lisa began to cry as the next bout of transfer practice was organized. Again, using motivational interviewing techniques, the therapist asked whether Lisa was in pain or overwhelmed. She mentioned that her husband passed away about 1 month before her motor vehicle accident. Upon learning this and making sure Lisa was not in the middle of a busy gym but in a one-on-one situation, the physical therapist offered to consult the medical psychiatric liaison nurse, and informed floor nursing staff, case management, and the primary medical service of all events and consults. After consultation with the case manager using the SBAR technique, acute rehabilitation was deemed to be an option for Lisa, because her level of function before accident was independent and she needed to be independent upon discharge. Because of the 75% rule,28 inpatient rehabilitation transfer was delayed and therapy continued in the acute care setting twice per day. The patient's functional level improved sufficiently to allow a safe discharge home with a hospital bed and assistance from her son, who flew in from another city 6 days earlier than originally planned, so Lisa would not be alone at home on discharge. Upon speaking with the patient regarding this new plan, she stated, “You were my inspiration!” and that she was comfortable with her discharge home.
Lisa's case highlights the need for clear narrative reasoning to truly understand what the situation meant to Lisa and her family. Without the interactive reasoning of the therapist (with Lisa, and with the case manager) and collaborative reasoning (for the possible inpatient rehabilitation stay), a comprehensive plan to organize a safe discharge for Lisa would have been impossible. Also, the careful replication of Lisa's home situation, as well as could be achieved in the hospital setting, highlighted significant safety and functional mobility deficits that might otherwise have not been obvious to the therapist in the hospital setting, and may have only emerged (with lack of safety in the home), or when she returned to the hospital after falling at home. By using motivational interviewing techniques, more insight was gained about Lisa's home situation, her unease at returning home, and her recent loss. In addition, because the therapist's interaction with Lisa was one-on-one and occurred over time, this allowed Lisa to open up to the therapist and share the recent loss of her husband, which was not previously mentioned in her medical record.
Although the examples above echo the daily experiences of many acute care physical therapists and assistants, the level of analysis of the situation is often lost to the fast pace of the acute care environment. These specific examples illustrate the profound impact that physical therapist examination, evaluation, and intervention have on patient outcomes and quality of care, and to offer tools for practitioners who find interprofessional dialogue to be challenging at times. By clearly delineating what aspect of clinical reasoning and combining this information with an effective communication technique, the health care team can best communicate interprofessionally as well as with the patient. Although no formal list of steps can assure that other professionals appreciate the depth and breadth of clinical relevance that physical therapy can bring to bear on overall patient management, what is apparent is that using data to define and support your clinical conclusions and recommendations will decrease the likelihood of these conflicts occurring. In addition, the SBAR method requires the inclusion of data to provide enough detail in the “situation” and “background” to lead to the “assessment” piece. Likewise, motivational interviewing stresses first gathering information about potential for behavior change to then allow details from data to be presented in support of the wanted behavior change. Communicating in a straightforward manner will help ensure the physical therapist's conclusions and recommendations are heard and considered in the overall plan of care.
Despite using the best measurements to define appropriate discharge parameters, interprofessional conflicts regarding timing and discharge disposition are part of every practitioner's experience. Sometimes this is due to limited resources upon discharge, for which “the best” option is chosen, much like when taking a multiple-choice test where instructions state to choose the best answer, though you may not be particularly enthralled with any of the choices. Many times, the primary medical service is asking for your recommendations on the day of discharge, and the results of the physical therapist evaluation found issues that were not known previously to the medical team. Sometimes, flexibility is possible in that day, but in Fannie's example where she was determined to not stay in the hospital, whatever could be done in 20 minutes was likely the best course of action. Keeping in mind the many variables that mattered to the patient at that moment, and doing follow-up education with the residents about how things could have happened differently and better in the future were key pieces to that scenario.
A reflective practitioner who can factor in multiple viewpoints and adapt care to the pertinent issues at hand will be successful. In the case of Jacob, the pertinent issue was to educate him to understand how he can best help himself to achieve his long-term goals of returning to a community level in the near future. Fannie's goals were shorter term and clearly defined. She did not realize that she needed a method to limit her risk of skeletal-related events, but was willing to start using a rolling walker as long as it did not undermine her goal of going home that day. Narrative reasoning strategies can assist in focusing clinical considerations while involving all members of the health care team. Clearly considering and being able to describe the narrative reasoning makes communicating these issues to other involved team members easier. Without the effective language to describe a therapist's clinical reasoning, communicating these issues becomes more difficult and may result in oversight of details, lack of understanding, or a missed opportunity that can result in a diluted outcome for the patient and the interprofessional team.
The most unfortunate example is when good reasoning and effort to provide the best care is disregarded, for example, when the patient is discharged inappropriately early or to the wrong setting. Focusing any interprofessional conversations about the patient and their needs, not about how your use of research and evidence is not being considered in relation to the safest disposition, is important. Both the motivational interviewing and SBAR techniques force the patient to the center of the discussion, and may ensure this oversight does not happen during interprofessional communication. Ethically and legally, you must document your findings and suggestions regardless of what the outcome will be as a result of other professional decisions, being sure to have also communicated your conflicting thoughts to the appropriate team member(s). We must also communicate our plans to document such without an abrasive or threatening tone, sticking to the facts and clearly stating the rationale both verbally and in the health record.
Therapists use multiple clinical reasoning strategies to achieve positive patient outcomes. Acute care physical therapists, because of the interprofessional nature of their practices in conjunction with short lengths of stay, need to be especially cognizant of how using clinical reasoning strategies to affect narrative reasoning can result in improved communication. Vital tools for all members of the interprofessional team include having communication techniques that allow collegial discussions among the health care team so as to reach the safest outcome for the patient.29
Portions of this content were previously presented as an educational session at Combined Sections Meeting 2013, San Diego, California, on January 23, 2013.
1. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84(4):312–355.
2. Higgs J, Jones M, Loftus S, Christensen N Clinical Reasoning in the Health Professions. 3rd ed. Amsterdam: Elsevier-Butterworth-Heinemann; 2008.
3. Jette DU, Grover L, Keck CP A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224–236.
4. Hayward LM, Black LL, Mostrom E, Jensen GM, Ritzline PD, Perkins J The first two years of practice: a longitudinal perspective on the learning and professional development of promising novice physical therapists. Phys Ther. 2013;93(3):369–383.
5. Masley PM, Havrilko C-L, Mahnensmith MR, et al. Physical therapist practice in the acute care setting: a qualitative study. Phys Ther. 2011;91(6):906–919.
6. Gorman SL, Hakim EW, Johnson W, et al. Nationwide acute care physical therapist practice analysis identifies knowledge, skills, and behaviors that reflect acute care practice. Phys Ther. 2010;90(10):1453–1467.
7. Smith M, Higgs J, Ellis E Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy. Physiother Res Int. 2008;13(4):209–222.
9. Vong SK, Cheing GL, Chan F, So EM, Chan CC Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011;92(2):176–183.
10. Jette DU, Brown R, Collette N, et al. Physical therapists' management of patients in the acute care setting: an observational study. Phys Ther. 2009;89(11):1158–1181.
11. Dussart C, Pommier P, Siranyan V, Grelaud G, Dussart S Optimizing clinical practice with case-based reasoning approach. J Eval Clin Prac. 2008;14(5):718–720.
12. Wainwright SF, Shepard KF, Harman LB, Stephens J Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Phys Ther. 2012;90(1):75–88.
13. Kanis JA, McCloskey EV Bone turnover and biochemical markers in malignancy. Cancer. 1997;80(suppl 8):1538–1545.
14. Demers LM, Costa L, Chinchilli VM, Gaydos L, Curley E, Lipton A Biochemical markers of bone turnover in patients with metastatic bone disease. Clin Chem. 1995;41:1489–1494.
15. Roodman GD Mechanisms of bone metastases. N Engl J Med. 2004;350(16):1655–1664.
16. Healey JH, Brown HK Complications of bone metastases. Cancer Supp. 2000;88(suppl 12):2940–2951.
17. Casimiro S, Guise TA, Chirgwin J The critical role of the bone microenvironment in cancer metastases. Mol Cell Endocrin. 2009;310(1–2):71–81.
18. Zimmerman EA, Launey ME, Barth HD, Ritchie RO Mixed-mode fracture of human cortical bone. Biomaterials. 2009;30(29):5877–5884.
19. Mac Niocaill RF, Quinlan JF, Stapleton RD, Hurson B, Dudeney S, O'Toole GC Inter- and intra-observer variability associated with the use of the Mirels' scoring system for metastatic bone lesions. Inter Orthop (SICOT). 2011;35(1):83–86.
20. Mirels H Metastatic disease in long bones: a proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989;12(249):256–264.
21. Savage PD, Ward WG Medical management of metastatic skeletal disease. Orthop Clin N Am. 2000;31(4):545–555.
22. De Backer D, Dubois MJ, Schmartz D, et al. Microcirculation in cardiac surgery: effects of cardiac bypass and anesthesia. Ann Thorac Surg. 2009;88(5):1396–1403.
23. Diringer MN, Zazulia AR. Hyponatremia in neurologic patients: consequences and approaches to treatment. Neurologist. 2006;12:117–126.
24. Howanitz JH, Howanitz PJ. Evaluation of serum and whole blood sodium critical values. Am J Clin Pathol. 2007;127(1):56–59.
25. Porter RS ed. The Merck Manual. 19th ed. Whitehouse Station, NJ: Merck Sharp & Dohme; 2011.
26. Chou CY, Chien CW, Hsueh IP, Sheu CF, Wang CH, Hsieh CL. Developing a short form of the Berg Balance Scale for people with stroke. Phys Ther. 2006;86(2):195–204.
27. Marchetti GF, Whitney SL. Construction and validation of the 4-item dynamic gait index. Phys Ther. 2006;86(12):1651–1660.
© 2014 by Lippincott Williams & Wilkins, Inc.