of PT programs used practical examinations to assess clinical reasoning skills, while many others used clinical affiliations, written examinations, or written assignments to evaluate clinical reasoning skills. Additionally, some institutions used multiple methods described above to assess clinical reasoning skills. This same study found that more than 90% of PT programs used the Physical Therapist Clinical Practice Instrument, followed by institution-designed grading rubrics, and other self-developed tools to assess clinical reasoning (Christensen et al., 2017). The variations in methods used to assess clinical reasoning, including specific tools used, translates to an inability to effectively and consistently assess the performance of learners. The assessments described above may measure student safety and performance of specific tests or measures, but these tools do not provide insight into the learner’s thought process, which is necessary for clinical reasoning to occur (Furze, Black, Hoffman, et al., 2015). A student may choose a “correct” test or measure, but without an explanation of why the student chose a particular test, the educator will not know if the student fully understands why the test is used or if there are any concepts that need to be explained further. For example, the student may have chosen to administer the Timed Up and Go test for a patient with mobility Clinical Performance Instrument (CPI) The Clinical Performance Instrument (CPI) is the tool most commonly used by students and clinical instructors in physical therapy to evaluate student performance during a clinical experience (Roach et al., 2012). The CPI evaluates two specific domains: 1) professional practice and 2) patient management. Clinical reasoning (Item 7 on this performance instrument) specifically assesses clinical reasoning and is categorized under patient management along with examination, diagnosis, Rubrics A number of rubrics have been developed to evaluate clinical reasoning skills in physical therapy (Baker et al., 2017; Fu, 2015; Furze, Black, Cochran, et al., 2015). Two of these rubrics, the Think Aloud Standardized Patient Examination (TASPE) and the Systematic Clinical Reasoning in Physical Therapy (SCRIPT), were developed to assess physical therapist clinical reasoning skills when working with patients who have musculoskeletal conditions, while the Clinical Reasoning Grading Rubric (CRGR) assesses general physical therapy skills for any patient (Baker et al., 2017; Fu, 2015). TAPSE The TAPSE allows the evaluator to immediately “see the learner’s thinking” by asking him or her to identify and justify the likely diagnostic hypotheses and appropriate interventions based on a standardized patient history and physical therapy examination (including special tests and measures). In this example, the learner must think and talk on his or her feet and justify the clinical decision-making process. The TAPSE was designed to specifically address the diagnostic reasoning component of clinical reasoning but does not address other parts of clinical reasoning such as collaborative reasoning where the learner interacts with other healthcare professionals in developing an interprofessional plan of care, or ethical reasoning where the learner weighs the moral and social factors into the decision- making process (Fu, 2015). The evaluator grades the learner on his or her clinical reasoning process using a continuum of performance ranging from excellent to poor related to “use of all relevant patient findings, use of both relevant and irrelevant findings, or use of irrelevant findings” (Fu, 2015). One limitation of this rubric is that it is only applied to patients with a musculoskeletal condition and thus may not be generalizable to patients with other health conditions.
limitations, balance dysfunction, and a history of three falls within the last month. However, when the clinical instructor asks the student why he or she chose this test over the Four Square Step Test, the student may say it was indicated because the Timed Up and Go measures how far the patient can walk. While the distance a patient can walk is important, in this case the Timed Up and Go test provides valuable information about the patient’s risk for falls. Other health professions also struggle to understand and assess clinical reasoning skills. Colleagues in medicine have identified barriers to assessment (Ratcliffe & Durning, 2015). These barriers include: 1) the collaborative nature of clinical reasoning, which is context dependent, 2) the lack of a “gold standard” for clinical reasoning, and 3) the variety of tools needed to assess and determine competence in clinical reasoning over a time frame versus a single point in time. Given the fact that an all-inclusive tool to assess clinical reasoning in physical therapy does not currently exist, a number of useful tools will be discussed below to provide the clinical instructor or mentor with a number of options to choose from depending upon the needs of the learner. intervention, assessment, and so on. This item asks the evaluator to rate how the learner broadly uses clinical reasoning skills by identifying sample behaviors. Although the CPI does identify clinical reasoning as one item on the assessment tool, it does not address this process in significant depth or allow for reflection through open-ended questions such as, Why did you choose the Berg Balance Scale? or What still confuses you about this patient? SCRIPT tool The SCRIPT tool was specifically designed for physical therapy fellows in an orthopedic manual physical therapy fellowship to provide a structure to guide the learner’s thought process when working with patients with musculoskeletal health conditions (Baker et al., 2017). Like the TAPSE, the SCRIPT focuses on the diagnostic component of the clinical reasoning process mostly due to the nature of the patient population in which physical therapists are determining the potential cause of the patient’s body structure and function limitations. The SCRIPT is a step-by- step process that prompts the learner to answer questions and prioritize information in an effort to determine the most accurate physical therapy diagnosis that translates into optimal patient care (Baker et al., 2017). CRGR The CRGR is used to assess clinical reasoning in a broad sense with various patient populations, not just patients with musculoskeletal health conditions. The CRGR was developed to assess the major constructs of clinical reasoning in PT practice (Furze, Black, Cochran, et al,, 2015). The authors developed this tool to assess the clinical reasoning skills in DPT students across a curriculum and with various patient populations. It was used as part of a clinical competency assessment to determine readiness to enter the clinical education environment. These types of rubrics used across the entire curriculum allow learners to view the 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 (Furze, Black, Cochran, et al., 2015). The CRGR consists of three domains of reasoning-- conceptual knowledge, procedural knowledge and psychomotor skills, and conceptual reasoning (Furze, Black, Cochran, et al., 2015). This tool incorporates components of selection, modification, performance of skills, identification of relevant context, and reflection.
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Book Code: PTCA2622B
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