Clinical Reasoning Physiotherapy

Clinical Reasoning in MusculoskeletalPractice: Students’ ConceptualizationsPaul Hendrick, Carol Bond, Elizabeth Duncan, Leigh Hale

Background. Qualitative research on physical therapist students’ conceptualiza-tions of clinical reasoning (CR) is sparse.

Objectives. The purpose of this study was to explore CR from students’perspectives.

Design. For this study, a qualitative, cross-sectional design was used.

Methods. Thirty-one students were randomly selected from years 2, 3, and 4 of anundergraduate physical therapist program in New Zealand. Students were inter-viewed about their understanding of CR and how they used it in practice in a recentmusculoskeletal placement. Interviews were recorded and transcribed verbatim. A3-stage analysis included the categorization of students’ conceptualizations on thebasis of the meaning and the structure of each experience and the identification ofcross-category themes.

Results. Five qualitatively different categories were identified: A—applying knowl-edge and experience to the problem, patient, or situation; B—analyzing and re-analyzing to deduce the problem and treatment; C—rationalizing or justifying whatand why; D—combining knowledge to reach a conclusion; and E—problem solvingand pattern building. Cross-category analysis revealed 5 general themes: forms of CR,spatiotemporal aspects, the degree of focus on the patient, attributions of confidence,and the role of clinical experience.

Conclusions. Categories formed a continuum of CR from less to more sophisti-cation and complexity. Students were distributed evenly across categories, except forcategory E, which included only students from years 3 and 4. Each category com-prised a logical, coherent experiential field. The general themes as critical dimensionssuggest a new way of exploring CR and suggest a possible pathway of development,but further research is required. These findings have implications for teaching and thedevelopment of physical therapy curricula.

P Hendrick, BSc(Hons), GradDipPhty,PGDMPhty, MMPhty, MNZSP, isProfessional Practice Fellow, Centrefor Physiotherapy Research, Schoolof Physiotherapy, University ofOtago, PO Box 56, Dunedin, NewZealand. Address all correspon-dence to Mr Hendrick at: [email protected] or [email protected].

C Bond, PhD, MCSP, is AcademicDirector, Student Learning Cen-tre, and Senior Lecturer, TheHigher Education DevelopmentCentre, University of Otago.

E Duncan, PhD, BSc(Hons), is Re-search Assistant, School of Physio-therapy, University of Otago.

L Hale, PhD, MSc(Physio),BSc(Physio), FNZCP, is Senior Lec-turer, Centre for PhysiotherapyResearch, School of Physiother-apy, University of Otago.

[Hendrick P, Bond C, Duncan E,Hale L. Clinical reasoning in mus-culoskeletal practice: students’conceptualizations. Phys Ther.2009;89:430–442.]

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Clinical reasoning (CR) is thethinking and decision-makingprocess used by practitioners.1

Research on CR in the health sci-ences has evolved over 3 distinct,but overlapping, phases, in whichthe shifts in focus have been accom-panied by differences in how CRwas understood and explained.2 Thefirst phase (1950s–1970s), whichfocused on the psychometric as-pects of reasoning and the develop-ment of measurement tools, contin-ues to be evident in tools used toassess CR skills.

The second phase was more cogni-tive and process oriented, con-cerned with specifying knowledgestructures and strategies,3 analyzingbehaviors, and eliciting steps inproblem solving.4,5 Clinical reason-ing was understood predominantlyas hypothetical deductive reasoning(HDR), comprising the generation ofhypotheses on the basis of priorknowledge and clinical data, induc-tive reasoning to generate hypothe-ses, and the deductive reasoningnecessary for the testing of hypoth-eses. Four components of HDR wereidentified: cue acquisition, hypothe-sis generation, cue interpretation,and hypothesis evaluation.6 Much ofthis research originated in occupa-tional therapy7 and was adopted andexpanded by recent work in physicaltherapy.8,9

Research in the third phase wasmore hermeneutic. It emphasizedsituated cognition and phenomeno-logical approaches,10 focused onunderstanding practitioners’ livedexperiences, and reflected theemerging movement toward patient-centered care.11 Clinical knowledgeand CR were interdependent; effec-tive CR required depth and organiza-tion of knowledge.12 Clinical reason-ing was understood predominantlyas pattern formation and recogni-tion,13,14 a process of perceiving andstoring related information to be re-

called and used as a prototype whena suitable stimulus was presented.Patterns were constantly revisedand reformulated,13 making CR amore transformative spiral model15

reflecting a cyclical, developmentalprocess. Each loop of the spiral in-corporated data input, interpreta-tion, and problem formulation toachieve a broader and deeper under-standing of the clinical problem; thismodel better matched the definitionof CR as a process of integratingknowledge, cognition, and meta-cognition.16,17 In contrast to CR inprevious phases, CR in the thirdphase was a process that appliedthroughout the interaction with thepatient.7 For this contemporary,multidimensional view of CR18 to beexplained and understood, more-complex integrated models had tobe developed.19

Teaching and assessment of CR skillsare key objectives of physical ther-apy education worldwide.20 Cur-rently, a range of tools are used toassess students’ CR skills.21–27 Eachtool tests different decisions regard-ing diagnostic hypotheses, investiga-tive actions, or treatment options,thus focusing on analyzing and mea-suring the processes used by thestudents rather than their under-standing of CR.21,25,27,28 Missing arestudies that focus on the students’own experiences, that is, the ways inwhich they conceptualize CR.

Knowledge of variations in students’conceptualizations of subject matteris important for teaching. Martonet al29 argued that teaching becomesa rational activity only when the in-structor understands what and howstudents discern or conceptualizethe phenomenon being taught.From a phenomenographic perspec-tive,30–32 a large body of researchshows that students’ conceptions oflearning influence the way in whichthey learn.33 Students who under-stand learning as repetitive memori-

zation tend to use simple strategiesand achieve a limited conceptuali-zation of the topic. In contrast, stu-dents who learn in order to under-stand a topic are likely to engage inactivities that promote understand-ing and achieve a more sophisticatedconceptualization. Given this re-search, it follows that students’ con-ceptualizations of CR are likely toinfluence the way in which they rea-son in the clinical setting.

The current study was prompted bymusculoskeletal (MS) clinical teach-ers’ concerns about the extent ofvariability in physical therapist stu-dents’ CR skills across the curricu-lum and most evident in the fourthyear of study. The aim of this re-search was to explore students’ con-ceptualizations of CR in the MScomponent of the physical therapycurriculum across the years to helpinform teaching of this complexskill.

MethodStudy ContextThe study was located in a physicaltherapy school at a university in NewZealand. The physical therapist pro-gram offered a 4-year undergraduatedegree and comprised a curriculumapproved by the physical therapyregulatory body in New Zealand—theNew Zealand Physiotherapy Board.

Year 1 of the program was a com-mon science foundation program forall students intending to enter healthprofessions. Years 2 to 4 were dedi-cated to physical therapy education.

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Years 2 and 3 focused predominantlyon principles and techniques, taughtmainly through lectures and practi-cal sessions; CR was embedded as akey objective and learning outcomein each topic of the 3 core disci-plines (MS, neurorehabilitation, andcardiorespiratory). In the MS compo-nent of the curriculum, CR was spe-cifically taught using HDR and pat-tern recognition through three1-hour lectures and 3 practical ses-sions in year 2 and two 1-hour lec-tures and 2 practical sessions in year3. A “problem-based” learning ap-proach was used, with integrationof CR models into case-based scenar-ios throughout the MS practicalsessions. In years 2 and 3, studentsundertook 162 hours of clinical prac-tice, during which clinical instruc-tors facilitated and reinforced the CRprocess. Year 4 comprised entirelyclinical practice, and the teaching ofCR was integrated experientially intothe students’ clinical training.

A qualitative, interpretive approachbased on principles of phenomenog-raphy, such as a second-order per-spective, internal relationship, andthe structure of experience,32 wasused in this research. In the second-order perspective, category mean-ings were defined by students’ expla-

nations of their conceptualizationsof CR rather than being based ondefinitions derived from previous re-search (ie, first-order or researchers’perspectives).32 Each student’s con-ceptualization of CR was treatedas a holistic experiential field inwhich aspects such as beliefs aboutphysical therapy and patients, learn-ing, reasoning, understanding, andknowledge were understood to bothdefine and internally relate one tothe other and define the whole ex-perience.34 Access to the meaningand structure of the students’ con-ceptualizations was gained throughquestions about what was under-stood about each aspect and how itwas understood (Fig. 1).

Design and SamplingThe study population comprised 360physical therapist students, 120 en-rolled in each of years 2, 3, and 4, inorder to gain an understanding ofstudents’ CR processes across thecurriculum. Students were informedof the research in lectures at thebeginning of the teaching year, as-sured that nonparticipation wouldhave no effect on their assessmentresults, and asked to volunteer. A to-tal of 56 volunteers were groupedby year of study and sex. Studentsfor whom English was a second lan-

guage or who had not completedan MS clinical placement were ex-cluded from the groups. A stratifiedpurposeful sampling approach byyear of study was used. Although thisapproach reduced sample size, it al-lowed sampling to cover a range ofcharacteristics that better definedthe phenomenon under study.35 Stu-dents were selected randomly fromeach group at a ratio of women tomen reflecting the actual sex distri-bution of the class. The final sampleconsisted of 31 students (20 womenand 11 men): 11 from year 2 and 10each from years 3 and 4 (Tab. 1).

ProcedureStudents participated individually inan audiotaped, semistructured, in-depth interview at the midpoint ofthe year, when all lectures and prac-tical sessions involving CR werecompleted. Interviews were sched-uled to take place within 3 weeks ofthe completion of the participant’sMS clinical placement (range�2–18days). Interviews, ranging from 30 to60 minutes, were conducted by thefirst and second authors. The firstauthor taught CR in the MS compo-nent of the curriculum but was notinvolved in the assessment of thestudy participants. Participants wereassured that their responses wouldhave no influence on their grades.The second author was previously aphysical therapist educator and co-ordinator of student learning devel-opment at The Higher EducationDevelopment Centre and is currentlyAcademic Director of the StudentLearning Centre at the University ofOtago. The third author was a PhDresearch student with a backgroundin science. To ensure procedural re-liability, the first and second authorsshared the task of conducting severalinterviews at the beginning of andlater in the process.

Interviews focused on what the stu-dents understood and how theywent about their practice. Partici-

Figure 1.Analytical framework for students’ conceptualizations of clinical reasoning (CR).32



pants were asked to describe exam-ples of their practice and to talkabout their understanding of CR,clinical knowledge or information,and learning and how they achievedthat understanding (Appendix). Theaudiotapes were transcribed verba-tim. The transcripts were checkedagainst the audiotapes by the thirdauthor.

Data AnalysisThe first and second authors under-took analyses separately to ensureunbiased category development. Thethird author audited the evolvingthemes and categories by checkingthem at regular intervals against theraw data to ensure validity. At eachstage of analysis (see below), re-searchers separately explored thedata in a search for evidence thatwould disconfirm evolving themesand categories.36 Regular researchmeetings in which each author’s as-sumptions about evolving themesand categories were reported, chal-lenged, debated, and clarified wereused as one strategy to ensure trust-worthy representation of the data.

The base unit of analysis was a stu-dent’s whole transcript. Analysiscomprised 3 iterative stages:

1. A crude initial reading and sort-ing, in which individual tran-scripts were read and grouped ac-cording to their similarities anddifferences, provided easier ac-cess to the large amount of com-plex data.

2. In a refined categorization, tran-scripts in each group were sub-jected to a detailed analysis. Dif-ferent aspects of a student’sconceptual field were noted andcompared with other aspects toestablish the meanings that thestudent associated with CR, prac-tice, patient care, learning, andknowledge. This analysis focusedon what the student understood

as CR, that is, the meaning as-cribed to both parts and whole;the structure of each aspect, thatis, how the experience was de-scribed; and the possible ratio-nale or logic for the relationshipbetween aspects, that is, why thestudent understood the experi-ence in the way in which he or

she described it. Intracategoryand transcategory similarities anddifferences were identified andcompared. Emerging categorieswere continually revisited and ad-justed to take into account thedata by use of the disconfirmationprocess outlined above. Detaileddescriptions of each category

Table 1.Allocation of the 31 Participants to Categories by Age, Sex, and Year in Program

ResearchPseudonym

Age(y)a Sex

Year inProgram

Conceptualization ofClinical Reasoningb

Lesley 20 Female 2 A

Malcolm 21 Male 2 A

Melvyn 24 Male 2 A

Shauna 22 Female 3 A

Hazel 22 Female 3 A

Patrick 21 Male 3 A

Kaley 21 Female 4 A

Kane 25 Male 4 A

Aiden 21 Male 2 B

Shayla 22 Female 2 B

Reagan 21 Male 3 B

Sinead 27 Female 3 B

Bevan 22 Male 4 B

Danelea 22 Female 4 B

Aeryn 23 Female 2 C

Ailsa 20 Female 2 C

Betha 20 Female 2 C

Maegan 19 Female 2 C

Annie 22 Female 3 C

Enya 23 Female 3 C

Genevieve 24 Female 3 C

Gallagher 25 Female 4 C

Kristen 22 Female 2 D

James 19 Male 2 D

Norah 23 Female 3 D

Ardara 24 Female 4 D

Alana 21 Female 4 D

Monaghan 38 Male 4 D

Sabrina 23 Female 3 E

Callahan 31 Male 4 E

Trevor 24 Male 4 E

a The average age of the participants was 23 years.b The numbers (percentages) for the whole sample were as follows: category A, 8 (26); category B, 6(19); category C, 8 (26); category D, 6 (19); and category E, 3 (10).



were prepared. Criteria for alloca-tion to categories were identified,and an individual’s experienceswere checked against the cate-gory descriptions and criteria.

3. Completed category descriptionswere subjected to a meta-analysisto identify general themes thatwere evident in different formsacross categories.

Credibility and VerificationSeveral strategies (shared interviews,audit trails, and disconfirmation)were used to ensure the credibilityand robustness of the research pro-cess and data analyses. Category de-scriptions were subjected to peer re-view and audit in 2 seminars, onewith 25 physical therapist facultystaff members at the location wherethe research was conducted and theother with 20 university academicstaff members. Feedback was invitedfrom the audiences, noted, and in-corporated into the research. In aseparate process, the fourth author(not involved in the original re-search) verified the conceptualiza-tions of CR and the cross-categorythemes on the basis of her experi-ences of CR in the physical therapycurriculum. She reviewed the audittrails through regular discussionswith the first 2 authors and step-by-step interrogation of the researchprocess and associated documents.

Ethics and the Role of theFunding SourceThis study was approved by the Hu-man Ethics Committee at the Univer-sity of Otago and was funded by aResearch Into University Teachinggrant.

ResultsThe results are presented in 2 parts:conceptualizations of CR as descrip-tive categories and cross-categorythematic variations.

Conceptualizations of CRAnalysis of the data in stages 1 and 2revealed 5 qualitatively differentconceptualizations of CR: categoryA—applying knowledge and experi-ence to the problem, patient, or sit-uation; category B—analyzing andreanalyzing to deduce the problemand treatment; category C—rational-izing or justifying what and why; cat-egory D—combining knowledge toreach a conclusion; and categoryE—problem solving and patternbuilding.

Category descriptions include themeaning (what) participants attrib-uted to CR and how they thought(the structural aspects). Quotations(identified by pseudonyms and thestudent’s year of enrollment, eg,“Hazel, 3”) illustrate each category.Table 1 shows the distribution ofparticipants by age, sex, year in pro-gram, and category.

Category A—applying knowl-edge and experience to the prob-lem, patient, or situation. In thiscategory, participants conceptual-ized CR in very general terms. Theirfocus was applying or relating whathad been learned (knowledge, expe-rience, evidence from examinationof the patient, or a combination ofthese) to a problem, patient, or situ-ation. Applying was described as fol-lows: “the application of the treat-ment procedures” or “doing it”(Hazel, 3), “you’ve got to try and . . .relate . . . what you know . . . to yourpatient” (Shauna, 3), or “. . . every-thing you’ve learned in the class-room, [seen and] used in the clinicalsetting, . . . you apply it to the pa-tient (Patrick, 3).

A therapist-centered view of bothphysical therapy and CR was evidentthroughout the data. The main con-cern was finding a technique that“worked” and was the “right thingto do” (Hazel, 3). Figure 2A shows alinear experiential structure. The di-

rection of application of knowledgewas from the student to the object ofapplication: the patient or the prob-lem. Feedback from the patient indi-cated “how effective the treatmenthas been” (Patrick, 3). However,there was little evidence to showhow the feedback was used, hence,the dotted line in Figure 2A.

Category B—analyzing and rean-alyzing to deduce the problemand treatment. In category A, stu-dents conceptualized CR predomi-nantly as a linear trial-and-error pro-cess. In contrast, category B was amuch more cyclical analytical pro-cess (Fig. 2B). Students spoke of an-alyzing and reanalyzing to deducethe problem and treatment relatingto the patient. They used all of theinformation available to them to de-termine possible scenarios, whichthen were continually narroweddown. The focus was on the processrather than the outcome. Clinicalreasoning was exemplified asfollows:

. . . just figuring it out . . . basically,it’s getting all the information . . . andtrying to come up, first with a hypoth-esis, then testing that and . . . , hope-fully, determining whether you’re onthe right track and narrowing downthat hypothesis to try and come to atreatment process. . . . And . . . thenevery other session doing all thatagain in a . . . smaller way . . . reana-lyzing and reassessing and determin-ing whether . . . for that patient(Sinead, 3).

Clinical reasoning continued tobe mainly therapist centered andtended to emphasize diagnosis.However, information about the pa-tient informed hypothesis formationand assessment. The direction of ap-plication of knowledge continuedto be from the student but focusedmore specifically on the patient andthe condition (Fig. 2B).



Figure 2.Diagrammatic representation of the structural aspects of students’ experiences with clinical reasoning.



Category C—rationalizing or jus-tifying what and why. Clinicalreasoning was conceptualized as jus-tification: “explaining why” (Annie,3), “rationalizing what you’re doing. . . using treatments and techniquesfor a specific purpose based on yourknowledge and experience” (Gene-vieve, 3), “the thinking behind thethinking . . . the reasons for why youdo things” (Betha, 2), and:

. . . being able to justify [to yourselfand to the patient] what you do, whatyou see, and what you think is goingon. . . . You might interpret what’sgoing on and then apply [a] certaintechnique for a certain reason. I thinkit’s taking the information, evaluatingit, and then responding to it in anappropriate way . . . it’s the wholeprocess of going through that (Gal-lagher, 4).

There was a focus for “why you . . .use techniques” (Enya, 3), “to see . . .the underlying cause of injury” (Aeryn,2), and “using evidence to suggest acertain outcome” (Annie, 3).

Structurally, the experience ap-peared circular (Fig. 2C). Studentsreferred to the importance of recog-nition and related their growing con-fidence to bringing together theirown knowledge and experiencewith their knowledge of the patient.They spoke of using their developingexperience of reasoning in new situ-ations. Unlike in categories A and B,in category C the patient was moreintegral to the experience:

. . . it’s their goals and their body . . .you might want to fix their ankle, butthey want to be able to play basket-ball or something . . . so it’s combin-ing it . . . [to] try and get that holisticapproach. . .you’re treating the wholeperson rather than a sprained ankle(Gallagher, 4).

Category D—combining knowl-edge to reach a conclusion. Clin-ical reasoning emphasized the end-point of the process (Fig. 2D).

Clinical reasoning was exemplifiedas combining knowledge to arrive ata conclusion, a decision, or a diag-nosis or to solve a problem: “. . . youjust combine things and eventuallycome up with a conclusion” (Alana,4) and:

. . . what you get from the patient, thesubjective and objective, . . . you putthat together with what you know,what other people tell you, and . . .clinical experience. You use all thattogether to make a decision . . . usingall your resources, putting themtogether to make a decision about apatient (Norah, 3).

This kind of combining differed fromthe concept of bringing knowledgetogether described for category Cabove. Students were aware of arange of possibilities and used a flex-ible approach that required an openmind:

. . . you’re really trying to keep anopen mind and anything they tell you. . . [you’re] trying to decipher if it’srelevant . . . you’re initially trying toarrive at a diagnosis, so you’re tryingto think of . . . a list of possible diag-noses, and the more they tell you[the] more you’re trying to narrow itdown to 1 or 2 possible suspects(Ardara, 4).

I think you’ve just got to keep anopen mind and . . . if you decide to dosomething and you realize that you’regoing along the wrong track, thenyou need to be able to change thatand do something else (Norah, 3).

When asked about HDR, studentsshowed a preference for forms ofsimple pattern recognition: “I don’tgo through it [HDR]. . . . I rely on myexperience . . . pattern recognition”(Monaghan, 4), “I don’t really gothrough the whole . . . [HDR pro-cess]” (Ardara, 4); rather, conclu-sions were based on “gut feeling”(Alana, 4) or a “leap of faith” (Mon-aghan, 4). Alana (4) talked about dif-ferent cases with similar signs andsymptoms:

. . . as soon as you see them you get afeeling . . . of what it’s most likelygoing to be . . . I’d say it’s some formof pattern recognition, but I haven’tseen many patients to get a patterngoing, but just from cases I heardabout recognizing signs and symp-toms that are similar. . . . Each personwill be slightly different, but therewill be 2 or 3 things that come uptime and time again.

Category E—problem solving andpattern building. Clinical reason-ing was exemplified as problem solv-ing and picture or pattern building(Fig. 2E), interrelated metacognitionprocesses that were not evident inprevious conceptions. Problem solv-ing, which tended to focus on thestudent’s experiences with individ-ual patients, was perceived as a con-tinuous, spiral process of planning,doing, and reflecting. Picture or pat-tern building was a more temporallyextended, visual process concernedwith individual patients, previousclinical experience, and the growthof knowledge and expertise. Bothprocesses involved more focus onthe patient than previousexperiences:

. . . it’s problem solving, really . . .each patient . . . gives you a set ofclues, and then you . . . look . . . atyour objective measures and . . . whatthey tell you and then try and builda pattern of what’s gone wrong andsee how that relates to a structure(Trevor, 4).

It’s not so much about the diagnosis. . . [although] it has a part to do withit, it’s how you get there . . . it’s whatyou’re given, what you see, what youprobe for, what you test, . . . you’re. . . thinking, “OK, is this adding to[the] picture?” If it isn’t, get rid of it. . . carry on until you’re happy inyour own mind that you have come toa conclusion based on evidence . . .[and] experience (Callahan, 4).

Callahan (4) asked, “Does the sub-jective [examination] . . . stack up[with] what you see objectively. . . .



Is there a fit?” Trevor (4) indicated,“There’s always the possibility thatit’s going to be other things, so I stillwent through all the different tests.”Callahan (4) described his approachto a patient as follows:

. . . when a patient says “shoulderpain,” . . . you go through all the pos-sibles . . . [suprascapular nerve dam-age is] not a very common thing at all. . . [we considered it because] shehad weakness. . . . I still went throughmy structured objective exam, but asI’m going through [it] I’m alwaysthinking what [it] could be, givenwhat the patient was saying; whatcould be at fault? . . . that’s what I dowith every patient, . . . they say some-thing and I think . . . to myself, itcould be this, could be this, could bethis, but not discount them all untilI’ve had a good check (Callahan, 4).

Students emphasized process be-cause it allowed them to “knowwhat they need to do next” (Sabrina,4). Yet, they also “deviate[d] fromthe process knowing that whenyou’ve exhausted the deviation . . .you can get back on track again be-cause you know . . . you’ve done it anumber of times” (Callahan, 4).Trevor (4) argued:

. . . having a logical sequence that youcan stick to each time so that as apattern develops, you can recognizeit . . . you can’t do exactly the samewith every patient but . . . in my as-sessment, I try to make sure that I’vegot clear what I want to work out—alogical sequence so you can build agood picture of the problem.

Sequence appeared to be the key tomore general pattern building:

. . . the more you deal with . . . pa-tients . . . you actually start to build upideas of how things happen and youcheck it out, and after you’ve doneabout 5 different patients with a sim-ilar thing, you actually start to see apattern forming with . . . their symp-toms or their signs or the way thingsworked, and those patterns actually

can apply a lot of the time. So, thenext time someone comes in andsays, “I do this and I’ve done that andthis hurts,” then you can go, “Well, Ithink it’s that because of. . . ,” . . .you’ve seen the pattern before inso many different other people(Sabrina, 3).

The therapist-patient relationshipwas a 2-way “linking [of] the theoryto the actual” (Sabrina, 3). Students’reasoning appeared to start with thepatient: “Every person’s different,so you link all the different ideas to-gether . . . with the person” (Sabrina,3). There was evidence that studentsintentionally set about building theirexperience, and they emphasizedthe ongoing improvement of theirclinical practice.

Cross-Category ThemesCross-category analysis (stage 3) re-vealed evidence of 5 general themes:(1) focus of CR, (2) spatiotemporalcharacteristics of CR, (3) differencesin the degree of focus on the patient,(4) variations in meaning and attribu-tion of confidence, and (5) role ofclinical experience in CR. Thesegeneral themes are summarized inTable 2.

Focus of CR. With the exceptionof category A, in which a trial-and-error approach predominated, somefeatures of HDR were recognizableacross all categories. In category B,there was evidence of analysis, test-ing of hypotheses, reassessment ofthe patient’s response, interpreta-tion and evaluation of information,and decision making using an active,albeit simple, feedback loop. How-ever, there was little reflection onthe process, and the narrow focuslacked the full breadth and depthof HDR. In category C, CR was adeeper, more-complex processbased on the rationalization of evi-dence. Categories D and E showedmore evidence of the stages ofHDR,37 including combining and

weighing information to rationalizedecision making6 and recognition ofthe importance of experience inpractice.38 Category D was con-cerned with both process and out-come, and students showed anincreased awareness of their limita-tions and the implications of CR.They talked about combining knowl-edge to reach a conclusion but alsomade reference to their use of intu-ition and the recognition of clinicalpatterns in the decision-makingprocess. They acknowledged thatpattern recognition was gainedthrough experience and practice.They realized that their applicationof knowledge and skills in the clini-cal environment had changed anddeveloped, but they quite oftenstruggled to articulate how decisionmaking took place and were awarethat reliance on a particular processcould sometimes hinder their rea-soning. There was evidence of astrong feedback loop for incorporat-ing knowledge and skills from arange of sources to inform practice.

Category E differed significantlyfrom the other categories. As withcategory D, students described pic-tures and clinical patterns. However,their focus extended beyond simplerecognition to an active and inten-tional development of such patternsby combining and weighing the in-formation against previous knowl-edge and experience. Clinical infor-mation and knowledge were used tobuild a “mental picture” to informcurrent management of the patient’scondition and future practice. Stu-dents also talked about reflection inaction and about action as a meansto build experience and informpractice.

Spatiotemporal characteristics ofCR. The spatiotemporal character-istics of CR changed across catego-ries (Tab. 2). “Spatio” is defined asthe boundary of the experience or“the space” it occupies. “Temporal”



is defined in terms of the student’sfocus in time. In each conception,space and time are integrally linkedand are described together. In cate-gories A and B, participants dealtonly with current time and the im-mediate task space. In category A,the student’s focus was the immedi-ate problem, situation, or applicationor effectiveness of a technique, andin category B, it was the immediatediagnosis. In category C, the tempo-ral focus included a single treatmentperiod and possible new situations,and the experiential boundary wasextended to include the manage-ment of the patient’s condition dur-ing treatment. In category D, thetemporal focus was the whole treat-ment period from diagnosis to con-clusion, and the experiential bound-ary was the student’s practice. Incategory E, the temporal focus wasvery broad, extending from pastexperience to the current situationand to future practice, and the expe-riential boundary was both the stu-

dent’s practice and the improvementof practice.

Differences in the degree of focuson the patient. Students’ concep-tualizations of the role of the patientin the clinical encounter changedacross categories from therapist cen-tered to a greater focus on the pa-tient (Tab. 2). In category A, therewas little or no reference to the pa-tient, and in category B, the refer-ence was limited to the student’s ca-pacity to provide explanations tothe patient. In category C, the pa-tient was recognized as an importantsource of information, and studentsfocused on their ability to providecare to the patient rather than theproblem. In category D, the patientwas central to the reasoning process,and students focused on the pa-tient’s goals. In category E, there wasa broader focus on the patient.

Variations in meaning and attri-bution of confidence. Confi-dence was mentioned in all catego-ries, but its meaning and attributiondiffered across categories. In cate-gory A, having confidence was asso-ciated with the effective perfor-mance of a technique. In category B,confidence was related to students’knowledge of a situation and its anal-ysis. In category C, confidence wasrelated to students’ ability to usetheir current knowledge to rational-ize the management of the patient’scondition. In category D, confidencewas based on whether studentshad experience with the conditionor had seen the situation before. Stu-dents also showed an increasedawareness of their limitations andthe implications of CR. In category E,confidence assumed a much broaderfocus on professionalism and deci-sion making on the basis of bestpractice.

Table 2.Summary of Cross-Category Themes and Variations Associated With Each Category

Conceptualizationof Clinical

Reasoning (CR) Forms of CRSpatiotemporal

Aspects

Degree ofFocus on the

Patient

Characteristic toWhich Confidence

Was AttributedRole of Clinical

Experience in CR

A: Applying knowledgeand experience to theproblem, patient, orsituation

Simple trial and error Immediate: the problem,the situation, or theeffectiveness of atechnique

Little or none:therapistcentered

The ability to performa particulartechnique

Prior experience withthe technique orproblem

B: Analyzing andreanalyzing to deducethe problem andtreatment

Analysis, testing ofhypotheses, andreassessment of thepatient’s response; use of asimple feedback loop

Immediate: the diagnosis Therapistcentered: youmust be ableto explain itto the patient

The ability to figure itout

Prior experience withthe condition

C: Rationalizing orjustifying what andwhy

More-complex processinvolving a form ofhypothetical deductivereasoning based on therationalization of evidence

The treatment periodand projection to newsituations

The patient is asource ofinformation

An awareness ofpersonal ability:how you put ittogether

Prior experience isrequired foreffective CR

D: Combining knowledgeto reach a conclusion

Combining and weighinginformation to rationalizeboth process and outcomedecisions; acknowledgingrecognized patterns

The whole treatmentprogram, fromdecision to conclusion

Focus on thepatient’s goals

Experience, practice,and seeing similarsituations

Prior experience iscrucial for patternrecognition

E: Problem solving andpattern building

Extending recognition ofclinical patterns to activeinvolvement in patterndevelopment, includingreflection and action

Past experience, currentsituation, and futurepractice, with a broadfocus on improvingpractice

Broadly patientfocused

The ability to beprofessional andbase decisions onevidence

Prior experience iscrucial for patternrecognition



Role of clinical experience in CR.Conceptions of the role of clinicalexperience in CR differed across cat-egories. In categories A and B, previ-ous clinical experience was neces-sary for the successful completionof a technique (A) or effective diag-nosis (B). However, in categories C,D, and E, the emphasis changed. Incategory C, students perceived theaccumulation of clinical experienceto be an important contributing fac-tor to CR, and in categories D and E,it was crucial to pattern recognition.

DiscussionThis study was undertaken becauseof the belief that good teaching de-pends on an understanding of stu-dents’ conceptualizations of the phe-nomenon being taught.29 Studentsconceptualized CR in 5 qualitativelydifferent ways across the 3 yearsof the undergraduate program, andconceptualizations ranged from verysimple to more complex. Moreover,students’ conceptualizations and de-scriptions of their approaches to CRappeared to be internally related inways that resembled research onconceptions and approaches to sub-ject material.33 Therefore, in cate-gory A, a student who understoodCR as an application or a way tomake something work used simple,linear trial and error in practice, thatis, applying a technique or aspect ofknowledge to the patient.

Educational research on conceptionsof learning has often reported cate-gories of conceptions as a hierarchyfrom simple to increasingly com-plex sophistication.33 The categoriesof CR reported above showed a sim-ilar pattern. Moreover, across catego-ries, shifts in emphasis from aspectsof HDR, task focus, and therapist-centered practice to embryonicforms of pattern recognition, pro-cess orientation, and more patient-focused practice resembled thosedescribed in research on novices andexperts.4,39,40 However, none of the

category descriptions resembled aparticular model of CR described inearlier literature. Rather, the cate-gories represented a continuumfrom relatively simple to increasinglycomplex, but mixed, forms ofreasoning.

The development of a continuum isfurther supported by the changeswithin the cross-category themes.Table 2 shows how each theme as-sumed a particular meaning in asso-ciation with the other aspects of itsrespective category. Yet, across cat-egories, each theme increased inbreadth, depth, and sophisticationfrom categories A to E. On the basisof these results and previous litera-ture, it may be argued that suchthemes represent key dimensionsof CR development. For example,the shift from therapist- to patient-focused care is well document-ed,37,41 and the development ofpatient-focused care is often a con-cern for clinical teachers.

The characteristics and themes of CRsuggest a developmental trend thatresembles the development of ex-pertise reported in the litera-ture.11–14 In particular, category Eshowed evidence of a more cyclicaland dynamic reasoning process,40 in-cluding a much broader focus andcritical self-reflection, recognized aspart of the evolutionary process to-ward independent practice42 and ex-pert practitioner status.37,43 The cat-egories showing more developmentrevealed CR to be a combination ofproblem solving and pattern recog-nition, and some of the characteris-tics of the spiral models of thinkingand reasoning11,44 were evident incategory E. The latter categoriesshowed signs of students’ increasingability to manipulate knowledge.14 Itwas also interesting that variations inexperiences mirrored, to some ex-tent, the changing views of CR in theliterature.

The sample included students from 3consecutive years of study. With yearof study as an indicator, it would beexpected that increasing expertise inCR would be evident as students pro-ceeded through their clinical pro-gram. However, this was not thecase. Although year 4 students wereassociated with a more sophisticatedand holistic experience of CR thanyear 2 students, two thirds of thesample experienced CR predomi-nantly in terms of categories A to C,in which the focus was immediatepractice, that is, diagnosis, treat-ment, or both (Tab. 1).

Application to TeachingStudents’ conceptions of and ap-proaches to learning are related tothe context (curriculum organiza-tion, teaching, and assessment) inwhich they learn.45,46 The curricu-lum was organized so that clinicalexperience was concentrated pre-dominantly in the fourth year. Thevariations in our results supportedthe clinical teachers’ observationsthat students’ capacity for CR variedsubstantially in year 4. This variationmay be attributable to several factors,including the possible influences ofother parts of the curriculum, thequality of clinical supervision, thecontext of the MS clinical place-ments,47 the clinical and theoreticalbalance in the curriculum, and theappropriateness of the assessment.The results suggest a need to exam-ine the relationship between thedevelopment of CR and clinical ex-posure as well as the alignment ofcourse objectives and assessmentwithin the curriculum.48

Dimensions of CR could be used toidentify where students are locatedon the continuum and, therefore,could contribute to the developmentof teaching, learning, and assessmentstrategies in the curriculum. For in-stance, students can be located onthe continuum by the language theyuse, their degree of focus on the



patient, their spatiotemporal char-acterizations of CR, and the ways inwhich they attribute confidence totheir practice. Students also couldmake use of such a tool as a reflec-tive device to aid in learning.

The results of this study emphasizethe need for clinical educators to ex-plore students’ conceptions and un-derstanding of reasoning in teachingand assessment. Teaching strategiesfocusing on, for example, particularviews of CR could be used to helpimprove student learning, and ge-neric strategies could be used toimprove students’ understanding ofCR. These generic strategies mightinclude using open-ended question-ing to extend students’ boundariesof thinking and focus; encouragingstudents to think beyond the text-book, for example, to explore theirprevious experience; enabling stu-dents to trust their observations; andusing metacognition strategies tohelp guide critical reflection.

Limitations and Further ResearchThese results may inform undergrad-uate physical therapist programs inAustralasia and Europe, but their ap-plication to doctoral programs mustbe made with some caution. How-ever, it is worth noting that 12 of the31 therapists (39%) in our sampleentered the physical therapist pro-gram as graduates, yet this cohortexhibited the same variations inconceptualization. Interestingly, all 3students who conceptualized CR ascategory E were graduate entrants.Although students’ conceptualiza-tions of CR in graduate programsmay differ, arguably the thematic di-mensions will remain the same inthat they reflect existing literature.

The cross-sectional design and con-straints imposed by single-schoolsampling make it impossible to domore than suggest a developmentaltrend. Clinical reasoning develop-ment and its influences can be inves-

tigated only through longitudinalstudies that track individual stu-dents’ progression in various physi-cal therapist programs. The general-izability of results to other physicaltherapy disciplines, such as neurore-habilitation, and to other programsrequires further research. It also isacknowledged that volunteer bias(ie, the majority of students did notagree to take part in the research)and student recall bias may haveinfluenced students’ responses topatient-related questions and, there-fore, may have influenced the distri-bution of conceptualizations of CR;however, these factors are unlikelyto have changed the range of con-ceptualizations of CR found in thisstudy.

ConclusionPreviously, CR was not exploredqualitatively using students’ directexperience as data. Further researchof this kind, in particular, longitudi-nal studies, may provide a new wayof exploring CR and an insight intoits development, teaching, and as-sessment. The continuum reportedabove for CR has the potential toprovide a method of assessing stu-dents’ understanding at a particulartime in their study. Such knowledgewould be extremely useful to teach-ers and students in the advancementof student learning.

Mr Hendrick, Dr Bond, and Dr Duncan pro-vided concept/idea/research design, datacollection, and consultation (including re-view of manuscript before submission). Allauthors provided writing and data analysis.Mr Hendrick and Dr Bond provided projectmanagement and fund procurement. MrHendrick provided participants, facilities/equipment, and institutional liaisons. DrDuncan provided clerical support. LindaRobertson assisted in checking and editingthe manuscript before submission.

This study was approved by the Human Eth-ics Committee at the University of Otago.

This study was funded by a Research IntoUniversity Teaching grant.

This research was presented at a researchseminar series at The Higher Education De-velopment Centre, University of Otago; Sep-tember 28, 2006; Dunedin, New Zealand.

This article was received May 20, 2008, andwas accepted February 2, 2009.

DOI: 10.2522/ptj.20080150

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Appendix.Interview Schedule

1. Let’s start with a question about you. Can you tell me a little about yourself? Age? Where you come from? Whatmade you choose to do physical therapy? (For mature students) What did you do before you enrolled?

2. You’ve completed a musculoskeletal module. I’d like you to think about the placement and choose a particularpatient with a musculoskeletal problem that you feel comfortable talking about.

Possible probes, depending on response:Tell me about them.What was the patient’s problem?Why did you choose this patient to talk about?What did you think when you first saw. . . ?What did you do?Why did you do that?What conclusions did you draw?Why did you come to those conclusions?Can you talk through the process you used to reach those conclusions?

3. What does the term “clinical reasoning” mean to you?

Possible probes:Can you tell me more about. . . ?What do you mean by. . . ?Why do you think that?

4. Can you provide another example of your own clinical reasoning in practice?

Tell me about the situation; what happened then. . . ?How did that come about?Why did you think that?

5. Where does the patient fit into clinical reasoning?

6. How do you think you have developed this idea of clinical reasoning?

Can you tell me more about. . .?What affected that development?What changed it?How has it changed?What was the effect of the physical therapy curriculum?

7. What is clinical information or clinical knowledge?

8. How do you learn in the clinical area?

9. What is learning for you—in the clinical area? More generally?

10. Do you have any other comments or questions?



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Clinical Reasoning Physiotherapy