P : The student PROBES the instructor by asking questions about what he or she does not understand. P : The student PLANS management for the patient. S : The student SELECTS a case-related issue for self- directed learning. (Wolpaw et al., 2003) This model is further described and applied below in Case study 1. Reflection As previously mentioned, reflection, whether written or verbal, is a necessary and powerful tool in the development of clinical reasoning skills. By promoting effective, meaningful reflection, clinical instructors, mentors, and academic faculty can capture the learners’ thought processes and gain a better understanding of their decisions. Encouraging learners to recognize and analyze relevant events and situations can promote development of the self-awareness skills necessary to synthesize the knowledge gained from a specific event and to apply this knowledge to future patient care situations (Wainwright et al., 2010). Many healthcare professionals are familiar with the time- dependent categories of reflection described by Schön: reflection-on-action, reflection-in-action, and reflection-for-action (Schön, 1983). Reflection-on-action is the type of reflection most individuals are familiar with as it occurs AFTER the event has taken place. The learner uses reflection to organize his or her thoughts or knowledge. For example, after a day in the clinical practice setting, the learner may reflect upon a challenging situation in which she is unable to determine why a patient with a stroke is limping on his right side. Reflection-in-action might also be called “real-time reflection,” because it happens in the moment. For example, if the therapist is working with a patient and notices that the patient looks confused when he or she is explaining an exercise, the therapist will immediately change his or her words or demonstrate the exercise so the patient can better understand the exercise. The therapist is able to interpret a potential misunderstanding during the session and adapt the instruction, rather than waiting until the next session for the patient to state he or she does not understand what the therapist is asking him or her to do (Wainwright et al., 2010). The last type of reflection, reflection-for-action, is an advanced skill in which the learner modifies future communication based upon previous experience. In the example provided above, the therapist who changed the exercise description and then demonstrated the exercise to the patient will now use this new strategy for future communications with patients. Novice learners primarily rely on reflection-on-action with little capability to reflect-in-action or reflect-for-action, while many expert clinicians frequently use reflection-in-action and reflection-for-action to make changes to a plan of care immediately to improve patient outcomes (Wainwright et al., 2010).
recruitment also factor into the pain. The CI asks the student how he knows that there is hypo- and hypermobility of various segments of the spine. The student responds: “I noticed this during my movement observation and it was confirmed by joint mobility testing on the patient.” The CI asks, “Do you have any evidence from the literature to support your thought process?” The student is unable to think of any at this time. Step 3: The CI explains to the student that there are numerous low back pain clinical practice guidelines available that the student and CI will discuss. The Orthopedic Section of the APTA has published guidelines in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) for low back pain and the U.S. Department of Veterans Affairs also has published guidelines. After this session the CI tells the student they will review the guidelines together in more detail. Right now, the CI says, “I just want you to rule out a few other things including malignant tumor, by asking the patient questions about waking up at night due to the pain and any weight loss, testing knee and ankle reflexes for neurological symptoms, and administering the Oswestry Low Back Pain scale to get a more objective idea of how this is impacting the patient’s function.” Step 4 : The CI comments that the student did a nice job gathering a thorough patient history to formulate an initial hypothesis of what was causing the patient’s pain, and determining appropriate tests to confirm the student’s thought process. The CI explains that a more thorough examination to rule out major red flags and to gain a more objective assessment of the patient’s function would be helpful to incorporate in the future. SNAPPS model Another teaching strategy that can be used in the clinical setting to facilitate clinical reasoning skills is the SNAPPS Model (Summarize, Narrow, Analyze, Probes, Plans, and Selects). This strategy may be more appropriate to use with a peer therapist, resident, or student in the later phases of the clinical curriculum because it places more of the onus on the learner to reflect upon areas to select for further study. The SNAPPS model is a six-step process in which the learner and educator engage in the following 5-minute process: S : The student briefly SUMMARIZES the patient history and current findings (approximately 2 to 3 minutes). N : The student NARROWS the differential diagnosis to two to three relevant possibilities. A : The student ANALYZES the differential diagnosis, comparing and contrasting the possibilities.
ASSESSING CLINICAL REASONING IN THE CLINICAL SETTING
Assessing or evaluating a learner’s clinical reasoning capacity can be very challenging given the dynamic process and multiple factors involved in clinical reasoning. First of all, it is hard to define something one can’t see, such as a thought or judgment. The clinical reasoning process is dependent upon the situation Complexity and richness of the clinical environment Applying clinical reasoning to clinical instruction or mentoring means that a learner may be able to select appropriate tests, measures, and interventions for a healthy 25-year-old soccer athlete with knee pain due to a meniscus injury, but may not be able to apply those clinical reasoning skills to a 52-year-old sedentary accountant with knee pain and multiple comorbidities. Clinical reasoning is associated with the learner’s “working knowledge” about a specific patient or condition as well as prior experience with the clinical situation (Lang, Schuwirth, Durning, & Rencic, 2015). Thus, novice learners will demonstrate decreased clinical reasoning skills when working with patients who have a condition that is unfamiliar to them. Given the fact
and the various factors involved in this complex activity. It is not a generic skill that can be learned in isolation and transferred to other settings with altered variables (Epstein, Shulman, & Spafka, 1978).
that learning clinical reasoning skills is context dependent, the clinical environment is the ideal setting for this learning to occur. Since this setting is where clinical reasoning skills are learned and demonstrated, it is also where they should be assessed. Given the complexity of the clinical reasoning process as described above, there are few standardized tests to evaluate clinical reasoning abilities specific to physical therapy (Huhn, Black, Jensen, & Deutsch, 2011). On a national scope, Christensen et al. (2017) surveyed physical therapy programs to determine how they were assessing clinical reasoning skills in students. The results of this study showed that more than 90%
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