getPTsmart.com way of learning

Our aim was to develop a structure that allows any PT student or novice practitioner practice their clinical reasoning skills independently, at their own time in the environment of their choice. To do this, we went through a long thought process of how to best structure and organise the website. We hit the databases, spoke with professionals and did a lot of self-reflection as to what we thought was effective learning. In this blog post we go further into the didactics of getPTsmart.com.

Attractive e-learning environment

Background

Clinical teaching in clinical setting is at the centre of medical education. However, as the clinic is the site of practice as well as of learning, conflicts of interest often emerge (Spencer in Grant 2008). Time and competing pressures on the clinician in his role as a teacher and a practitioner often make deliberate teaching of clinical reasoning in a clinical setting sparse and difficult to manage (Grant 2008, Rencic 2011).

Integrated solution & benefits

  • Online clinical reasoning is potentially a highly effective and powerful support for learning & teaching clinical reasoning (Ryan et al. 2004, Grant 2008).
  • The general benefits of distance learning methods, i.e. accessibility in time & space, quality- assured material, ease of use and cost-effectiveness, fit well into the concept of distributed system of practice applied in education of health sciences.
  • Learners require longer time in processing data than experienced clinicians (Rencic 2011) and the time-independent environment allows learners to take the time they need to for each clinical reasoning step.
  • A web application makes it possible to deliver learning material via different media (online, print-out, video). Multi-modal learning has been proven to be more effective than uni-modal learning (Fadel et al. 2008) and students appear to wish to retain printed text that offers active learning, problem solving and feedback (Grant 2008).
  • An e-learning platform offers a stimulating learning environment with a fresh and inspiring look & feel.
  • A web application is easy to update and extend ensuring that the content continuously matches the latest concepts and available evidence in physical therapy.

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.

References

  • American Physical Therapy Association (APTA). Interactive Guide to Physical Therapist Practice. Alexandria: American Physical Therapy Association; 2003.
  • Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Phys Ther. 2011;91:416-30.
  • Fadel C, Lemke C. Multimodal learning through media: what the research says [online]. San Jose: Cisco Systems Inc; c 2008 [last update March 2011; cited 2011 Nov. 1]. URL: http:// www.cisco.com/web/strategy/docs/education/Multimodal- Learning-Through-Media.pdf.
  • Grant J. Using open and distance learning to develop clinical reasoning skills. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam: Elsevier; 2008. p. 441-9.
  • Harman K, Bassett R, Fenety A, Hoens A. ‘I think it, but don’t often write it’: the barriers to charting in private practice. Physiother Can. 2009;61:252-8.
  • Kesselring J, Coenen M, Cieza A, Thompson A, Kostanjsek N, Stucki G. Developing the ICF Core Sets for multiple sclerosis to specify functioning. Mult Scler. 2008;14:252-4.
  • Pistorius MF, Ramaekers SP, Verhoeven AL, Becht MJ, Bloo JK et al. The professional profile of the physical therapist. Amersfoort: Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF); 2006.
  • Ramaekers S. On the development of competence in solving clinical problems: can it be taught? Or can it only be learned? [PhD thesis]. Utrecht: University of Utrecht; 2011.
  • Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil. 2008;44(3):329-42.
  • Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach. 2011:1-6.
  • Rothstein JM, Echternach JL, Riddle DL. The Hypothesis- Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83(5):455-70.
  • Ryan G, Dolling T, Barnet S. Supporting the problem-based learning process in the clinical years: evaluation of an online Clinical Reasoning Guide. Med Educ. 2004;38(6):638-45.
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