Exploration of Students' Clinical Reasoning Development in Professional Physical Therapy Education

INTRODUCTIONIn the current dynamic health care environment, patients often present with numerous comorbidities within a multifaceted social and economic context, while insurers continue to limit payment for necessary services. In order to meet clinical practice demands, educators are responsible for clearly understanding the development of clinical reasoning abilities and facilitating student development of strong clinical reasoning skills.Clinical ReasoningUnderstanding the clinical reasoning process is challenging, given the complexity of factors that contribute to the reasoning process and the variety of definitions that exist in the health professions literature.1'3 For example, clinical decision making, critical thinking, and clinical reasoning have been used interchangeably to describe the same phenomenon. For the purposes of this paper, the authors chose to operationally define these terms. In the broadest and most general sense, clinical reasoning can be summarized as the thinking and decision making of a health care provider in clinical practice.4 Essentially, clinical reasoning is the critical thought process and judgment behind one's action,5 whereas clinical decision making is the action that is taken on this process.6 To better understand this difference, it may be helpful to think that one can make a decision without any reasoning or thought process behind that choice. Nikipoulou-Smyrni and Nikopoulos define clinical reasoning as a reflective process that engages the patient and family in collaborative decision making, taking into account the critical contextual factors to determine an appropriate clinical intervention.7 Using this definition, one can see both contextual and cognitive aspects of clinical reasoning. Consistent with other definitions, critical thinking would be a component of the cognitive aspect of clinical reasoning.8 Critical thinking as a cognitive skill involves inductive and deductive thinking, evaluation, and analyses, but does not encompass judgment, reflection, or the many contextual factors that are a part of clinical reasoning.8 Clinical reasoning is complex because it involves the application of cognitive, affective, and psychomotor skills while using a reflective thought process to make decisions and judgments based on a patient presentation.9Emphasis on clinical reasoning in education has been reported in medicine, dentistry, occupational therapy, physical therapy, and nursing.10 In fact, the American Association of Colleges of Nursing (AACN) has stressed the importance of developing and assessing clinical reasoning skills in nursing students as part of nursing education.11 A recent call for radical transformation in nursing education includes an emphasis on clinical reasoning and multiple ways of thinking, which will enable nurses to practice safely, compassionately, and accurately in different practice settings.12 Similarly, the American Physical Therapy Association (APTA) also identifies clinical reasoning as a skill and practice expectation described in the Normative Model of Physical Therapist Education,13 yet a comprehensive approach for facilitating and assessing clinical reasoning across physical therapy education programs has not been clearly established.4The advancement of any skill is developmental in nature and requires practice over time. Dreyfus and Dreyfus proposed a framework of skill acquisition that may be applicable to the development of clinical reasoning abilities in physical therapy students.3,14,15 This model has been applied in medicine and nursing to describe various benchmarks (novice to expert) along the continuum of clinical skill development, as well as key characteristics/traits associated with each level.16,17 The Dreyfus model originally described the developmental model of skill acquisition when observing the progress of pilots and chess players over time.14,15 In the model, the learner passes through 3 phases when moving from novice to expert. …