As the physical therapy profession continues to evolve and mature, expectations of physical therapist (PT) practice must also grow to respond to the needs of society.1,2,3 Physical therapists are increasingly accountable for their professional actions, decisions, and patient outcomes within a seemingly ever-changing, fast-paced health care environment. Given this concurrent increase in autonomy and accountability, development of clinical reasoning processes for PTs is an important focus across education and clinical practice settings. Although numerous and variable definitions exist,4–7 clinical reasoning can be defined as the sum of the critical thinking and decision-making processes associated with clinical practice within the health professions.6 Reasoning is a reflective activity in which the PT engages the patient and family in a collaborative decision-making process that acknowledges key contextual factors that will affect clinical interventions and patient outcomes.7 Reflection, mutual decision making, and understanding the contextual variables specific to an individual patient are important aspects of the clinical reasoning process. Other dimensions of clinical reasoning include the therapist's grasp of discipline-specific knowledge, the ability to engage in metacognition or reflective self-awareness,8 an understanding of patient- and family-centered focus,5 and a commitment to ongoing learning through the development of clinical expertise.9
At the Section on Pediatrics (SoP) Education Summit in July 2012, focused discussion supported the need to include explicit instruction in clinical reasoning as an essential component of pediatric PT education.10 The concept of clinical reasoning as a foundational and complex aspect of education and practice within the health professions has evolved over recent decades and can be simplified into 2 general types of reasoning processes: deductive and inductive.4,11 Deductive reasoning strategies include use of the hypothetico-deductive method and emphasize hypothesis generation on the basis of information gathered from the patient through interviewing and questioning to develop an initial hypothesis.12–14 Using a deductive reasoning approach, additional information including results from tests and measures is collected and interpreted in a cyclical process to disprove or confirm a hypothesis or diagnosis by comparing options. In contrast, inductive reasoning strategies typically involve recognition of familiar clinical patterns and identification of the patient-specific contextual factors, ambiguities, and challenges that affect the care of an individual patient without actively comparing and contrasting options.15–17 Inductive reasoning strategies usually require patient experience and familiarity with a situation to form a clinical pattern. Table 1 provides a case example that illustrates the differences in thinking that occur between deductive reasoning (hypothetico-deductive) and inductive reasoning (pattern recognition) strategies. Physical therapists often rely primarily on a specific reasoning strategy; however, both deductive and inductive strategies may be used in different clinical scenarios or when a preferred strategy is not effective for a given situation.9,18
Although the importance of helping students develop clinical reasoning skills is well documented in the literature,18–20 PT education, and education in general, often emphasizes evaluation of student performance that is focused on the single correct answer. This is in contrast to preparing students to identify and solve problems through the inherent uncertainties of clinical practice.5,18,19 As Salvatori21 explains, “moments of difficulty often contain the seeds of understanding,”p81 and through this difficulty educators can begin to see the misconceptions or misunderstandings that may be occurring in a student's thought process. Helping students identify the difficulty or uncertainty in a clinical situation can bring forth opportunities for deeper and more complex forms of thinking. For example, after a hands-on experience with a child with special needs, asking the student to reflect and describe parts of this child/family interaction that were still puzzling or difficult to understand can help the educator to determine what “pieces of the puzzle” the student is still missing. Typically, students may have difficulty providing the appropriate verbal cues to children of different ages in a way that motivates the child, or understanding the prognosis for the child as he/she ages. Student uncertainty in these situations should not be viewed as a sign of failure or shortcoming but rather as an opportunity for improved understanding and comprehension.21
Academic faculty and clinical instructors may lack the tools necessary to assist students in developing the processes and abilities for clinical reasoning to occur.19,20 When working with students, the focus is often more on refining psychomotor skills and performance and less on facilitating thinking or reasoning skills. Teaching clinical reasoning skills in pediatric PT practice is often further compounded by additional challenges as academic faculty and clinical instructors strive to bring students' attention to key aspects of practice that may be unfamiliar to the student such as age-appropriate health and safety concerns, consideration of a child's developmental level across all domains of function, and the need for family-centered care. Whether in the classroom or in clinical education, educators must be able to gain insight into students' thinking, which has been called “getting the inside out.”22 Educators cannot help students identify misconceptions and misunderstandings if they do not know what students are thinking. Without these insights into students' thought processes, students may be processing information incorrectly or incompletely. As an outcome of the SoP Education Summit in 2012, the purpose of this article is to provide academic faculty and clinical instructors with an overview of various pedagogical strategies and tools that can be used to teach students clinical reasoning skills and to facilitate the development of both deductive and inductive reasoning strategies in pediatric PT practice. Strategies and assessment tools for use in both the classroom and clinical education settings are presented.
OVERVIEW OF TEACHING AND LEARNING TOOLS
Reflection as a Tool in Developing Clinical Reasoning Skills
Clinical reasoning processes are best taught within the context of patient care and clinical cases.23 As shown in Figure 1, experience and exposure to clinical practice alone, however, are not sufficient to develop clinical reasoning skills. Developing clinical reasoning skills involves reflection and an analytical, progressive method of addressing patient-centered problems. Students must learn to consistently reflect on and learn from specific patient-related contextual situations in order to transform their critical thinking structure and process in a progression toward clinical expertise. Reflective activities in both the clinic and in the classroom allow students to challenge their thinking and make connections between concepts or theory, and clinical practice. Furthermore, as students engage in a reflective, self-monitoring process, they are learning the critical importance of self-awareness and humility that is foundational to the development of professional values.24,25 Of additional importance to educators, reflection not only allows students to contemplate and ponder key aspects of a specific patient-related experience, but also offers educators a way to “get the inside out” and see what students are thinking.22
Similar to the development of clinical reasoning skills, the ability to use various types of reflection can be viewed as a developmental continuum. At one end of this continuum, clinicians retrospectively employ reflection-on-action techniques to look back on the difficulties or challenges of a specific patient encounter after the fact.24 At the opposite end of this continuum, clinicians use reflection-in-action in a feed-forward manner to reshape their actions and decisions on the basis of unexpected or surprising events that occur in real time.24 Although expert PTs are able to “stop the action” and employ reflection-in-action and reflection-for-action processes to respond to clinical situations and problems as they unfold,24,26–28,32 students typically reflect upon patient-related experiences after the encounter occurs using reflection-on-action to learn from and improve their future performance.24 Such reflection may occur through formal or informal processes that encompass both written and oral methods. To be most effective as an instructional strategy, reflection should involve more than simply recalling the details of a specific event or patient encounter. Reflection should ideally be structured and purposeful, requiring the student to both ponder the experience and identify challenges, difficulties, or inconsistencies within the experience. Incorporating reflective questions, such as “Based upon this experience, what would you do differently in a future situation?” and “Why would you change your actions?”, encourage the student to re-engage in the experience to reinforce learning. Reflecting on a clinical encounter may also promote a broader understanding and deeper sense of meaning that allows the student to approach subsequent experiences in a different and more enlightened manner. Preferably, reflection should also involve collaborating with others within a professional community to exchange viewpoints and engage in patient-centered problem solving.29,32,33 When incorporating reflection into teaching and learning, it is important to note that the learning environment should be set up in such a way that the student's perspectives and views are valued and that the student feels safe enough to reveal his/her true feelings. The educator must also be open to the novel thoughts, emotions, and ideas that are often expressed during reflection and help students understand that multiple appropriate perspectives often exist in clinical practice.21
As depicted in Figure 2, teaching clinical reasoning entails achieving a balance between deductive reasoning strategies that provide structure and concrete variables with inductive reasoning strategies that emphasize patient-specific context within the uncertainty or difficulty of a clinical situation. As portrayed in Figure 1, clinical reasoning processes develop over time and therefore represent a developmental progression within a PT's growth toward clinical expertise.17,26–28,30 Evidence suggests that novice PTs are more likely to use therapist-centered, deductive reasoning approaches, which emphasize the therapists' thought process and gathering of tests and measures such as the hypothetico-deductive reasoning model.5,33–35 Thus, for the student or novice learner, deductive reasoning is often emphasized early in educational programs as students develop analytical and critical thinking skills.34,35 In contrast, inductive reasoning strategies, such as pattern recognition and forward reasoning methods within a collaborative, patient-centered model where the contextual factor of the patient serves as the primary source of information, are more frequently used by experienced or expert clinicians.31–34 Such inductive reasoning strategies require the therapist to quickly process and categorize information into clinical patterns.11,30 Given that inductive reasoning strategies are less structured and require that the student have some patient care experience, inductive reasoning strategies are often best used later in the curricular sequence after the student has had some clinical education experience and can draw upon a variety of clinical scenarios.
Deductive Teaching and Learning Tools
In the health professions and in physical therapy in particular, numerous deductive tools including frameworks, models, and algorithms exist to facilitate the clinical decision-making and reasoning process of the learner.14,36–40 The most commonly used deductive tools in PT education are discussed below.
The International Classification of Functioning, Disability, and Health
The International Classification of Functioning, Disability, and Health (ICF)36 may be helpful to use across both classroom and clinical education settings to guide PT students through the process of identifying various contextual factors primarily seen in the personal and environmental factors categories that may influence the clinical reasoning process for a specific patient. Mapping out the ICF as it applies to specific patient cases (paper or video cases in the classroom and actual patients in clinical education) can provide students with a structure to help organize their thought processes while at the same time allowing educators to “see” the students' thoughts. In this manner, use of the ICF can help ensure the student is able to identify key aspects of a developmental or health condition and how a child's condition may contribute to impairments in body structure and function, activity limitations, and restrictions in participation. Pinpointing case-specific internal and external factors within the ICF ensures the student can recognize essential contextual factors necessary for the application of clinical reasoning processes. Contextual factors include aspects of the patient's situation that lead to complexity or uncertainty. For example, it may be more challenging for a pediatric PT to develop a feasible home program for a single mother with 10 children who is working 2 jobs to financially support her family than it might be for a 2-parent family with 2 children and a parent that works in the home. In this case, the contextual factors of single parenthood, caring for multiple children, and working 2 jobs make the development of a home program more complex.
Educators can also use the ICF to help students appreciate the effect of a child's developmental or health condition at various points across the lifespan. For example, issues related to the development of secondary musculoskeletal impairments such as joint contractures and bony deformities may not be readily apparent to a student working with an infant who has spastic quadriplegic cerebral palsy. Using the ICF to capture key areas of concern as the child ages and grows may help the student to understand the importance of considering the potential for secondary musculoskeletal impairments in infants with developmental conditions.40 A longitudinal case report by Palisano et al41 further illustrates how educators can use the ICF to help students understand how the concerns and priorities of a family and child may change over time depending on the child's age (infancy vs young adulthood vs older adulthood). Other tools such as the Physical Therapy Clinical Reasoning and Reflection Tool,38 developed as a clinical refection tool and guide for professional development, incorporate the ICF and may be helpful in facilitating the reasoning process while developing components of clinical expertise.15,26
Clinical algorithms provide a systematic approach to patient care and therefore may help guide students through the clinical reasoning process. Examples of such algorithms include the Hypothesis-Oriented Algorithm for Clinicians (HOAC)14 and the HOAC II.37 Both the HOAC and the HOAC II are independent of any particular theoretical approach and were designed to assist PTs in any setting to address the physical therapy needs of their patients/clients. Both the HOAC and the HOAC II can be applied to pediatric PT practice.39,41 Students, however, may require greater prompting and assistance to methodically work through situations and scenarios commonly presented in pediatrics. The Hypothesis-Oriented Pediatric Focused Algorithm (HOP-FA)40 is a clinical framework that provides a systematic, step-wise guide to clinical reasoning in pediatric PT practice. At each step within the HOP-FA, the student is asked to consider various factors and issues that may affect the clinical reasoning process for a particular child and family. Designed for use in both clinical education and the classroom, the HOP-FA includes forms developed to assist educators in using the framework to guide students in the application of the HOP-FA to specific patient cases.
Inductive Teaching and Learning Tools
Inductive reasoning tools are used to help students uncover patient-specific contextual factors in an effort to understand the deeper meanings that are essential to the management of the case to begin to build clinical knowledge.18 Compared with the number of deductive reasoning tools, far fewer teaching tools facilitate the development of inductive reasoning skills.
One tool that provides a structure and process for engaging students in uncovering and understanding the contextual factors associated with patient care is narrative writing. A clinical narrative is a form of reflection that involves recollection and description of an actual clinical event that has some significance because the event allowed learning or comprehension to occur.43–45 When writing a narrative, the student is instructed to describe in the first person a situation where something new was learned or when a memorable interaction or difficult situation occurred. The inclusion of feelings, specific details, and the students' thoughts throughout the narrative description is encouraged. In the narrative, students describe what they know about the clinical situation along with the areas with which they struggle or have difficulties. This tension between what is known and what is unknown creates an opportunity for learning as well as a portal, into the students' thought processes.44 Narratives provide important opportunities to identify the complexity of clinical practice and the rich contextual factors associated with practice.30,45 Content knowledge and practice are clearly linked in a meaningful process when writing a narrative.45,46 A narrative can be used as an inductive method of revealing the student's clinical reasoning process.
Educators in both the classroom and in clinical education can use the purposeful use of questioning techniques to help PT students to rethink and reframe a seemingly routine patient case. “What if” questions can be particularly useful in this regard: “What if this family were homeless? What additional concerns and considerations would homelessness bring to the case?” “What if the child had a progressive condition? How would that potentially affect the selection of a seating and mobility device?” “What if we were seeing this child in a school setting instead of in an outpatient clinic? What additional factors would need to be considered in the examination process?” Questions that ask students to think toward the future can also be helpful: “What do you expect this child's functional abilities to be in 1 year? In 5 years? What needs to be done now to maximize this child's future independence?” Questions that force learners to prioritize patient problem areas can also help students consider and justify specific aspects of a patient case: “What single impairment is most limiting to this patient's gait function? Why?” “What single factor is most limiting this patient's desired participation in a community-based dance class? What can a PT do to address this issue?”
Questioning can also be used to focus a student's attention on various aspects of a particular patient case. For example, students should learn to consider the potential effect of multiple contextual factors such as the child's age, developmental level, family dynamics, and the environment. Questioning can help students to recognize salient contextual factors in a case: “How does this family view their child with special needs?” “What is the family's view of their child's power wheelchair?” “How does this child interact with his siblings?” “How might this child's use of an augmentative communication device affect the physical therapy plan of care?” Questioning can also be used to facilitate the student's understanding of the process of differential diagnosis. For example, in a case related to persistent bilateral toe walking, questioning may include: “What aspects of the case history support a diagnosis of idiopathic toe walking?” “What aspects contradict this diagnosis?” “What signs and symptoms in the case support a neurological basis for the toe walking?” “If a progressive neuromuscular condition was the cause of the child's toe walking, what additional signs and symptoms would you expect to see?”
OVERVIEW OF ASSESSMENT TECHNIQUES
Because of the complexity and multiple variables associated with reasoning processes, assessment of clinical reasoning is challenging for educators in both academic and clinical education settings. Few standardized tools exist to evaluate PT students' clinical reasoning abilities.47 A majority of the available assessment instruments, such as the Health Science Reasoning Test48 and the California Critical Thinking Skills Test,49 evaluate only the cognitive component of clinical reasoning and do not pertain specifically to PT practice.47
Clinical Reasoning Grading Rubric
A model clinical reasoning grading rubric tool was developed to assess the major constructs of clinical reasoning in PT practice and is provided in Appendix A (Supplemental Digital Content 2, available at http://links.lww.com/PPT/A88).50 This rubric was developed as part of an evolving scholarship of teaching and learning research project investigating the clinical reasoning abilities of doctor of physical therapy (DPT) students over time in a specific professional education program.51 Use of rubrics such as this throughout the DPT curriculum allows students to explicitly view progression (from beginner to proficient) in their reasoning process. In addition, academic faculty and clinical instructors can identify specific student learning needs and offer guidance aimed at the individual student's level. Another advantage of this tool is that it can be used beyond entry-level practice to assess the reasoning process of residents or clinicians. This rubric was created to meet a program's identified need to effectively and explicitly capture the students' clinical reasoning process.50,51 The following core components were embedded into the Clinical Reasoning Grading Rubric: learners' use and application of types of knowledge (content and procedural), selection, modification, and performance of skills, identification of relevant context, and reflection.
Although narratives are used as a teaching tool to facilitate the clinical reasoning process, they can also be used to assess a student's reasoning process by allowing the educator to see the student's thoughts and thinking process. Including narratives as part of practical examinations or in clinical education could be a powerful assessment tool. Teachers are responsible for identifying and correcting students' misconceptions. The use of narrative is a powerful tool in uncovering these misconceptions.21,22 Such narratives may also help track the development of a student's clinical reasoning skills over time to provide evidence of areas of strength and components needing improvement.
Multiple pedagogical tools and learning strategies to facilitate and assess the clinical reasoning process of the learner have been poised throughout this article. In this section, we describe how the tools provided might be implemented in the clinic and the classroom. A balance of both deductive and inductive strategies should be used to facilitate the clinical reasoning process. To illustrate how this might occur, the following case will be applied across various points in the curriculum:
A 5 year-old boy with Down syndrome is seen by a PT in the outpatient setting. His medical history includes premature birth at 34 weeks postconceptual age, feeding and speech difficulties, and asthma. His mother reports he is having difficulty keeping up with friends at school and when playing outside. He lives with his mother who works full-time and 2-year-old sister in an apartment building on the 2nd floor with stairs leading to home in an urban, underserved area. His mother is involved in his care when she is not at work and is concerned about his inability to keep up with his friends and his subsequent withdraw from recreational sport activities, particularly soccer.
Deductive tools, such as the ICF or the HOP-FA, may be most useful in providing students with structure and guidance in exploring the case. The educator may choose to simplify the above case for the novice learner to the following basic components: “a 5-year-old child with Down syndrome is seen in the outpatient physical therapy setting to improve his endurance and activity level so he can play with his peers at school and participate in soccer.” As seen in Figure 3, the ICF model can be used to provide the novice learner with some initial structure in analyzing the case. Appendix B (Supplemental Digital Content 3, available at http://links.lww.com/PPT/A89) demonstrates how select tools from the HOP-FA could be used as a deductive strategy in either the academic or clinical setting. In the clinical education setting or after a hands-on laboratory experience in the academic setting, students could write a clinical narrative describing their thoughts and feelings about the most difficult aspect of working with this child. Table 2 illustrates an excerpt from a sample clinical narrative that highlights a student's struggles and difficulties with this case.
The concept of difficulty or uncertainty may also be addressed by asking a student to answer the following questions: “What parts of the case/interaction are still puzzling or uncertain for you?” “Describe why this is still challenging for you.” “Can you provide an example of uncertainty that remains after interacting with the child/family?” In addition, open-ended questioning techniques could also be employed such as, “How do you expect this child's gross motor abilities to compare with his peers who are typically developing? How might this change over the next 5 years?” “How might this child's asthma affect playing soccer? What can be done to help him and his family learn to manage his asthma?” Questions that require students to prioritize patient problem areas can also help them to consider and justify specific aspects of a patient case and might include “What single impairment is most limiting to this patient's endurance and activity level and why?” “What single factor is most limiting to this patient's desired participation in soccer?” and “How does this child's cognitive status affect the physical therapy plan of care?”
Teaching clinical reasoning skills in both the classroom and the clinic is a complex and yet vital aspect of PT education. Across the curriculum and in both the clinic and the classroom, a balance of deductive and inductive reasoning strategies should be used to facilitate the development of students' clinical reasoning processes. For educators, a shift in teaching, learning, and assessment may be required to move PT education from its current focus on knowledge and evaluating student performance for the single right answer to include an expanded emphasis that links building a knowledge base and skill development with the development of thinking and reasoning skills.11,52 Academic and clinical educators have responsibility for facilitating the learning process, which includes the ability to have insight into the thinking and reasoning process of the student as he or she develops over time. The use of specific teaching strategies and tools can help facilitate this important process of linking clinical reasoning development with knowledge and skill development.11,52
The authors thank the SoP of the American Physical Therapy Association for their support of the Education Summit in July 2012 and recognize the following Summit attendees: Suzann Campbell, Donna Cech, Lisa Dannemiller, Paul deRegt, Paula A. DiBiasio, Jennifer Furze, Gail Jensen, Lisa Kenyon, Heather Lundeen, Kathy Martin, Victoria A. Moerchen, Kelli Parks, Eric Pelletier, Mary Jane Rapport, Joe Schreiber, Ellen Spake, and Sheree York.
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