Purposeful clinical reasoning

Background

The clinical reasoning work process consists of gathering information, interpreting meaning, making judgements, making decisions and organising findings (Ramaekers 2011, p. 48). Development of cognitive skills including data analysis, data synthesis and enquiry strategies is at the heart of development of clinical reasoning strategies and professional growth (Atkinson et al. 2011).

Integrated solution & benefits

• The users are stimulated toward deliberate and conscious problem solving process as advocated by Pistorius et al. (2006) and Ramaekers (2011) by the means of the action to take. The cyclical clinical reasoning work process is implemented in the actions to take and follow the same structure in each clinical reasoning section. The reasoning process is thereby continuously repeated without repetition.
• Learning is maximised by encouraging users to activate their existing knowledge base before starting to work with the case (Rencic 2011, Ramaekers 2011).
• The users are encouraged to make use of ICF Core Sets in the first clinical reasoning section. The Core Sets facilitate systematic and comprehensive description of functioning in clinical practice and protect the therapists from missing important aspects of functioning (Kesselring et al. 2007, Rauch et al. 2008).
• Provision of patient information at correct times in the clinical reasoning process resembles challenges of real clinical practice and give the users opportunities to practice managing complex clinical problems without overloading their working memory (Ramaekers 2011).
• The yellow sticky notes give the users additional guidance, support and motivation in the clinical reasoning process.

Active clinical reasoning: real-life case studies

Background

A key issue in education is to reduce complexity of real-life situations, problems and questions to a level that students can handle, learn and progress (Ramaekers 2011).

Integrated solution & benefits

• Authentic, real-life cases provide an opportunity to engage in solving and handling problems typically and a-typically meet in real practice. They provide better opportunities to engage in meaningful learning and bridge the gap between education and professional practice (Ramaekers 2011).
• Case validation by experienced teachers of clinical reasoning ensures functional fidelity, meaning avoidance of overload as well as scarcity of provided information (Ramaekers 2011).
• Cases at different level of complexity enable users to select a case to match their skill level. Easy, medium and complex cases provide variation and ensure that users can progress in developing their clinical reasoning skills on getPTsmart.com.

Feedback & reflection

Background

Learners are generally poor at self-assessment, making external feedback essential (Rencic 2011). Together with development of knowledge and cognitive skills, metacognitive skills including self-awareness and reflection are essential for development of clinical reasoning skills (Atkinson et al. 2011).

Integrated solution & benefits

• Comparison of users own solution to provided and expert-validated solution is a way to raise the level of deliberate practice (Ramaekers 2011).
• The provided case solutions give insight to possible alternative approaches in solving the case and provide feed-forward for managing similar problems in clinical practice (Ramaekers 2011).
• Continuous reflection slows down the clinical reasoning process and is a way to avoid premature decision-making (Rencic 2011).

PT Client Management Canvas (in short ‘Canvas’)

Background

Charting and documenting the decision making process is central to clinical reasoning, quality of client care and essentially to professional accountability (Rothstein et al. 2003, Harman et al. 2009). Good charting practice is imperative not only for evidence and justification of treatment approaches but also for tracking and solving trends and problems so that coherent continuity of treatment is ensured. Poor documentation has a potential to reduce the effectiveness and quality of physical therapy practice and improvements in charting are needed (Harman et al. 2009). We could not find an existing tool for charting and documenting a HOAC II – based clinical reasoning process and therefore decided to develop a data recording tool, the ‘PT Client Management Canvas’, or simply the ‘Canvas’.

Integrated solution & benefits

• The Canvas provides a way for us to manage case information, explicitly to avoid redundancy of information and allows us to give the users short and precise, yet complete data to work with. The Canvas allows for effective communication between us and the users.
• The Canvas is easy to use in clinical settings and thereby enables the users to apply the same HOAC II way of clinical reasoning they have learned on getPTsmart.com in practice.
• The basic structure of the Canvas includes four sections reflecting the four elements of patient management: initial data, problem tracking (including progress monitoring), examination and intervention (APTA 2003).
• The type and extend of information gathered during the initial data collection is a choice of the clinician and reflects his approach to practice (Rothstein et al. 2003). Therefore, the initial data sheet consists of free space where the user can record any relevant information in his preferred way. When preferred, the free space also allows the user to draw in the Rehabilitation Problem Solving (RPS) form.
• Adequate documentation of the evidence used (e.g. best practice guidelines, ICF core sets, brief notes on rationale based on scientific principles) is ensured by inclusion of a ‘guidelines, evidence & remarks’ box.
• The ‘problem tracking’ sheet gives the user an overview of the identified problems and the baseline situation. This information directly guides the user in the formation of a goal fulfilling the criteria of the SMART-acronym.

Man’s mind, once stretched by a new idea, never regains its original dimensions.

– Oliver Wendell Holmes

Closing with this wise statement, we certainly hope that the getPTsmart.com way of learning helps students and novice physical therapists in their process of becoming better PTs.