Role of conceptual models in a physical therapy curriculum ... · Role of conceptual models in a physical therapy curriculum: Application of an integrated model of theory, research,

Role of conceptual models in a physical therapy

curriculum: Application of an integrated model of

theory, research, and clinical practice

Johanna Darrah, PhD,1 Joan Loomis, MEd,2 Patricia Manns, PhD,3

Barbara Norton, BScPT,4 and Laura May, PhD5

1Professor, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada2Associate Professor and Associate Chair, Department of Physical Therapy, University of Alberta,

Edmonton, AB, Canada3Assistant Professor, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada

4Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada5Associate Professor, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada

The Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada, recentlyimplemented a Master of Physical Therapy (MPT) entry-level degree program. As part of the curricu-lum design, two models were developed, a Model of Best Practice and the Clinical Decision-MakingModel. Both models incorporate four key concepts of the new curriculum: 1) the concept that theory,research, and clinical practice are interdependent and inform each other; 2) the importance of client-centered practice; 3) the terminology and philosophical framework of the World Health Organization’sInternational Classification of Functioning, Disability, and Health; and 4) the importance of evidence-based practice. In this article the general purposes of models for learning are described; the two modelsdeveloped for the MPT program are described; and examples of their use with curriculum design andteaching are provided. Our experiences with both the development and use of models of practice havebeen positive. The models have provided both faculty and students with a simple, systematic structuredframework to organize teaching and learning in the MPT program.

Introduction

The Department of Physical Therapy at theUniversity of Alberta, Edmonton, Alberta,Canada, recently introduced a master’s degreeprogram to replace the baccalaureate degreeprogram to prepare students for entry-levelpractice. During curriculum development, weidentified four concepts to guide our decisionsregarding curriculum design and development.The first is the belief that the students needed

to understand that theoretical frameworks usedto explain and justify clinical intervention strate-gies, research findings from the literature, andclinical skills all contribute to their clinicaldecision making in physical therapy practice.The second concept is the importance of client-centered practice in decision making. The thirdconcept is our commitment to integrate thephilosophy and language of the InternationalClassification of Functioning, Disability, andHealth (ICF) (World Health Organization,

Accepted for publication 6 October 2005.

Address correspondence to Johanna Darrah, PhD, Professor, Department of Physical Therapy, 2-50 Corbett Hall,

University of Alberta, Edmonton, AB, T6G 2G4 Canada. E-mail: [email protected]

Physiotherapy Theory and Practice, 22(5):239�250, 2006

Copyright # Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online

DOI: 10.1080/09593980600927765

239

2001) into the students’ learning. The fourthconcept is that students would value and demon-strate evidence-based practice when makingclinical decisions. We incorporated these fourconcepts into two models that we wanted bothstudents and faculty to use to guide learningand teaching in the program. These modelsbecame the ‘‘blueprint’’ for making curriculumdesign decisions, for writing course syllabi,and, once the program was initiated, for guidingteaching structure and content. Both modelsincorporate the four concepts but for differentpurposes. The overarching model, Client-Oriented Research and Evaluation Leads to BestPractice (CORxE) (Figure 1) uses the fourconcepts as a framework for the students to

understand how their learning in the programis structured around these concepts. The secondmodel is the Clinical Decision-Making Model(Figure 2), which uses the four concepts to guidethe students through the more specific, iterativeprocess of client assessment, intervention, andevaluation of outcome.

Models: definitions, uses, and types

Practice guidelines are common for specificintervention practices, but there are few modelsthat provide a general framework of physicaltherapy practice. Models can be used as amethod of knowledge management for any

Figure 1. CORxE model of best practice.

240 Darrah et al./Physiotherapy Theory and Practice 22 (2006) 239�250

profession and can be defined as ‘‘a mechanismto convert information into actionable knowl-edge’’ (Vail, 2000). Three uses of models thatare applicable to physical therapy are 1) toenhance understanding by simplifying com-plexity, 2) to encourage learning by efficientlystoring knowledge in concise and easy to useterms that assist the learning of complex rela-tionships, and 3) to facilitate effective communi-cation by providing a common structure andlanguage (Vail, 2000). Rothstein and Echternach(1986) defined a model as a conceptual schemethat provides a guide for therapists with evalu-ation and treatment planning through the useof a logical sequence of activities, and they sug-gested that effective models are independent ofspecific treatment philosophies.

Before designing our own models, weconsidered five models from the physical ther-apy literature to adapt for our program: theHypothesis-Oriented Algorithm for Clinicians(HOAC) (Rothstein and Echternach, 1986), theHypothesis-Oriented Algorithm for CliniciansII (HOAC II) (Rothstein, Echternach, and

Riddle, 2003), the Collaborative ClinicalReasoning Process (Jones, Jensen, and Edwards,2000), the Interrelationships of Theory, ClinicalModel, and Research (Cooper and Saarinen-Rahikka, 1986), and the Evidence-Based Prac-tice Circle (Thomson-O’Brien and Moreland,1998). All of these models are well developedand contribute to the clinical decision-makingprocess in physical therapy, but none of themincluded all four concepts that we had identifiedas being integral to our new curriculum.

We advocate the use of models as a method ofsynthesizing and integrating important conceptsin practice for educators, students, and clini-cians. While developing the new curriculum,the faculty in our department agreed that amodel incorporating the concepts of our curricu-lum would enhance both our organization anddesign of the curriculum and student learning.This process was guided by curriculum designtheories that stress the importance of defininga platform of beliefs and vision and a structureto implement curriculum principles (Shepardand Jensen, 2002).

Figure 2. CORxE clinical decision-making model.

Darrah et al./Physiotherapy Theory and Practice 22 (2006) 239�250 241

The generation and refinement of the modelsprovided a basis for excellent discussions duringcurriculum development. Harris (1993) outlinesthe central importance of deliberation to cur-riculum decision making in effectively bringingtogether diverse sources of knowledge and per-spectives to achieve consensus. Lively discussionamong faculty explored previously assumedrelationships between goals, assessments, inter-ventions, and outcomes. As a result, we wereable to make collaborative decisions aboutcourse content and coordination.

In this article we describe the development of thetwo models and demonstrate how we used them toguide curriculum development and how theycontinue to guide student learning in the nowestablished entry-level master’s degree program.

Model 1: client-oriented research andevaluation leads to best practice(CORxE)

We refer to this model (Figure 1) as ourModel of Best Practice. The arrows linking‘‘theory,’’ ‘‘assessment and intervention,’’‘‘research,’’ and ‘‘evaluation and outcome’’ formthe periphery of the circle and represent the inte-gration of theory, research, and clinical practice.The arrows are bidirectional to remind facultyand students that the three knowledge sources,theory, practice (assessment, intervention, evalu-ation, and outcome), and research inform andinfluence each other simultaneously. Theoryguides and explains practice, but clinical obser-vations in practice can also be used to questionand to modify theories. Knowledge from theresearch literature also needs to be consideredin clinical decision making. This outer circlereminds students of the powerful connectionsamong theory, practice, and research and thatinformation from all three sources is importantin clinical practice. Often the clinical relevanceof theory and research is not easily identifiedin practice, and we wanted the students tounderstand that all components can inform eachother and that all three concepts contribute toclinical decision making.

The figures in the center represent the centralimportance of patients=clients and their families.The philosophy of client=patient-centered prac-tice is an essential attribute of current practice.

Documents, such as the American PhysicalTherapy Association’s Guide to Physical Thera-pist Practice (American Physical TherapyAssociation, 2001) and the Commission onAccreditation of Rehabilitation Facilities (Bakeret al, 2001), emphasize the essential role ofpatients=clients in decision making and inestablishing goals and objectives. We placedthe client and family in the center of our modelto emphasize their importance.

Both the arrows on the periphery of themodel linking ‘‘theory,’’ ‘‘assessment and inter-vention,’’ ‘‘research,’’ and ‘‘evaluation and out-come,’’ and the dominance of the client=familyin the center of the circle emphasize the impor-tance of evidence-based practice in our curricu-lum. We identify evidence-based practice byusing Sackett’s definition of evidence-basedmedicine: ‘‘the integration of best research evi-dence with clinical expertise and patient values’’(Sackett et al, 2000, p. 1). The CORxE modelcontent exemplifies these concepts of evidence-based practice.

The International Classification of Function-ing, Disability, and Health (ICF) (World HealthOrganization, 2001) is an international classi-fication of health status that can be used to clas-sify the health status of all persons. The ICFclassification system defines different categoriesof health by the components of body functionsand structures (physiological and anatomical)and activities and participation (task and lifeareas). This classification and common languageprovides students with a systematic way to clas-sify client problems, goals, and outcome mea-sures. It also encourages them to evaluate therelationship among interventions and outcomes.Clinically, we often assume that intervention atthe component of body function will have aneffect on a client’s performance at the compo-nent of activity. For example, it is often assumedthat lower limb muscle strengthening (body func-tion) will influence the ability of a client to walkefficiently on different surfaces (activity). TheICF cautions against such assumptions andprovides a framework to systematically evaluatethe relationships. The ICF also acknowledgesthe influence of contextual factors on a client’sabilities. Contextual factors can be environmen-tal (physical, social, or attitudinal) or personal,representing attributes of a person (e.g., age,gender). The ICF is a biopsychosocial model


of health (Bickenbach et al, 1999) that providesa framework to evaluate the influence of bothintrinsic and extrinsic factors on a person’s per-formance in all areas of function.

For our curriculum, the ICF provides both acommon language for categorizing client pro-blems, therapy goals, intervention strategies,outcome measures, and a philosophical frame-work to evaluate the relationships among bodyfunction and structure, activity, and partici-pation and environmental factors. It is centralto the design and implementation of the newprogram. In the CORxE model we included theICF contextual factors terminology to remindthe students (and faculty) that physical therapyassessments and interventions must always con-sider the personal and environmental contextualfactors that each client brings with him or her.A person’s environmental context must be con-sidered during assessments, goal setting, andchoice of intervention strategy.

During curriculum development of theCORxE model, we recognized the importanceof facilitating an understanding of all four con-cepts represented in CORxE within and acrosscourses. For example, we agreed that in thenew curriculum we needed to formally introducethe theory and philosophy associated with cli-ent-centered care and evidence-based practice.In our previous program these concepts werediscussed by individual instructors, but therewas no formal mechanism to track the students’incremental learning of these process skills in asystematic manner. When developing everycourse syllabi in the new curriculum, instructorshad to include research literature pertinent tothe clinical content, and seminars had to inte-grate research and clinical skill knowledge. TheCORxE model helped us all to standardizecourse content to include these important com-ponents.

Table 1 illustrates a practical example linkingthe model to one course objective and the learn-ing experiences, evaluation methods and out-comes associated with that course objective.The course objective, as documented in thestudent syllabus, is directly derived from theclinical decision-making model. The researchliterature is used as a starting point; studentsare also expected to independently search theliterature. The CORxE model is explicitly usedto organize the knowledge outcomes, which

assist the students to, in turn, organize theirlearning. This learning activity promotes reflec-tion for action (hypothesis generation), reflec-tion-in-action (active learning in group work),and reflection-on-action (wrap-up activity inlarge group) (Plack and Santasier, 2004).

With the implementation of the new program,the CORxE model provides a framework toguide student learning. Students expect aninstructor to identify the components of theCORxE model that are introduced or reinforcedin each course. Students are encouraged to askeach instructor, ‘‘Where does this fit in theCORxE?’’ Our vision is that the CORxE modelwill ground the students’ learning and help themto organize their knowledge across courses. Webelieve that if both students and teachers usethe CORxE Model of Best Practice as a learningguide, students will integrate and synthesizeinformation across courses, rather than com-partmentalize facts within courses. Thus, weare using the model to allow the students toefficiently integrate large amounts of knowledgeand to emphasize the relationships amongknowledge learned in different courses. Inconjunction with the CORxE Model of BestPractice, we also designed the second, comp-lementary Clinical Decision Making model, onthe basis of the same four concepts. This modelis more detailed and is designed to guide the stu-dents’ management of clinical decision makingand the concomitant documentation of pro-blems, assessment, intervention, and outcomes.

Model 2: CORxE clinicaldecision-making model

The term clinical decision making is often usedinterchangeably with the term clinical reasoningin physical therapy, but the terms have impor-tant differences in meaning. Clinical reasoningrefers to the more abstract thought processesand strategies used by clinicians to make clinicaldecisions (Higgs and Jones, 2000), whereas clini-cal decision making represents the concrete out-comes of clinical reasoning such as diagnosis,goals, and management strategies (McAllisterand Rose, 2000). The CORxE ClinicalDecision-Making Model is applied more directlyto client management than the CORxE Model ofBest Practice model and was developed to guide


students in the process of collecting pertinentinformation, identifying problems, generatinggoals, making intervention decisions, and evalu-ating the outcome.

Figure 2 illustrates the CORxE ClinicalDecision Making model. The model is set againstthe background of the CORxE Model of BestPractice as a reminder that it is based on the fourconcepts represented in the CORxE model. Theclient=family icon in the center has been expandedto emphasize that goal setting must be a colla-borative process and that both the client and thetherapist contribute information and knowledgeto the process of identifying the goal. The clientbrings his or her values and knowledge of the pre-senting problem, and the therapist uses his or herskills, knowledge, and previous experience to

define the problem. The model also reminds stu-dents that the goal identified from the presentingproblem is influenced by the external contextssuch as access and availability of health careresources, funding, legal and professional regu-lation, and ethics. Students are encouraged toidentify functional problems and goals ratherthan impairment-based problems. They are alsoadvised not to use a medical diagnosis as the prob-lem. For example, for a client presenting withhemiplegia after a stroke, the presenting problemshould not be hemiplegia, but rather a functionalproblem at the ICF components of activi-ty=participation such as inability to climb stairsin the home or poor walking endurance.

After collaborative agreement on a goal withthe client, the student’s next step is to identify

Table 1. Practical example of linkage between models and curriculum.

Example specific to hip fracture scenario (see Appendix A)

Course objective . Demonstrate the ability to independently integrate theoryand research into assessment, intervention, and outcomemeasure choices.

Research readings . Sherrington C, Lord SR, Herbert RD 2004 A randomizedcontrolled trial of weight-bearing versus non-weight-bear-ing exercise for improving physical ability after usual carefor hip fracture. Arch Phys Med Rehabil 85(5): 710�716.

. Handoll HH, Sherrington C, Parker MJ 2004 Mobilisationstrategies after hip fracture surgery in adults. CochraneDatabase Syst Rev 4: CD001704.

Teaching method . Student group meetings (6�8 students per group) focusedaround learning of knowledge outcomes (as documentedin Appendix A), guided by instructor provided questions.

. Subsequently, 20 to 30-minute instructor-led large group(�70 students) wrap-up at the end of each session toensure students are gaining the appropriate knowledgeand skills from the scenario, as they work in their smallgroups.

. Instructors may ask new discussion questions in the largegroup session or ask for skill demonstrations by the stu-dents. The ability to answer these questions or successfullydemonstrate the task indicates an understanding of thematerial and an ability to apply that material.

Evaluation . Groups of 6�8 students are evaluated by using a newpatient case. One evaluator grades both the contributionof each individual to the group and the group perform-ance. See evaluation form in Appendix A.

Outcome=application . Students will be able to confidently and competently assessand treat a person with hip fracture postsurgically.


possible causes of the functional problem(hypothesis generation). Within the CORxEClinical Decision-Making Model, the therapist’s‘‘educated guess’’ about the factors causing theproblem is considered the hypothesis. This is con-sistent with the view of hypothesis described in theHOAC II (Rothstein, Echternach, and Riddle,2003). Each of these suspected causal factors canthen be systematically examined during the assess-ment phase. The three bidirectional arrows point-ing to the ‘‘evolving concept of the problem’’reminds students to use information from theirdiscussions with clients, assessment findings,theory, and research to generate hypotheses.Hypotheses can be modified or changed com-pletely, depending on the information gathered,including information from research sources. Wehave tried to capture this iterative process by usingthe term ‘‘evolving concept of the problem.’’

We used ICF terminology to structure theassessment, intervention, and outcome evalu-ation processes. As described previously, theICF is organized into two parts: 1) Functioningand Disability and 2) Contextual Factors. Eachpart has two components. Functioning and Dis-ability is divided into 1) Body component,including body structures (anatomical parts)and body functions (physiological) and 2) Activityand Participation, including aspects of function-ing at both person (activity) and societal (partici-pation) components. The Contextual factors partis divided into 1) Environmental factors, includ-ing physical, social, and attitudinal influences,and 2) Personal factors that represent personalattributes. For each component there are bothpositive and negative terms. Impairment denotesa deficit at the component of body function orstructure, whereas a deficit at the componentof activity is termed an activity limitation. Thedeficit term for the component of participationis participation restriction. We have used thepositive terminology in the assessment part ofthe model to remind students to evaluate thestrengths of the patient as well as the identifieddeficits. During the assessment process, for eachproblem or goal, the students identify factors atthe components of body functions and structures,activities, and participation, and the contextualfactors that have an impact on the problem ineither a positive or negative manner. Forexample, if an elderly woman with osteoarthritispresented with the problem that she was no

longer able to garden, the problem may becaused by pain (impairment), limited range ofmotion at her hip and knee joints (impairment),inability to kneel (activity limitation), or thesheer size of her garden (environmental physicalbarrier). These factors each represent a hypoth-esis of why she is experiencing the presentingproblem of her inability to garden. During theassessment phase the student will systematicallyevaluate the possible influence of each identifiedhypothesis.

Decisions about interventions are informedby information from four sources. First, the cli-ent’s values and needs must be considered.Second, the therapist (student) brings his orher experience with similar clients and problems.Third, either the client or therapist, or both, cancontribute research knowledge from the litera-ture concerning intervention options. All threeof these sources of information, which representevidence-based practice as we have defined it,are used in conjunction with the fourth infor-mation source, the assessment findings, toformulate an intervention plan.

Intervention decisions can focus on a strategyof adaptation, recovery, or prevention. An adap-tation intervention approach suggests that solu-tions to compensate for the identified problemmay include either adaptation of the client’smovement solutions or adaptation of theenvironment (contextual factors). This inter-vention decision may be made in cases in whichthe client is not expected to regain previousmotor performance (e.g., after spinal cordinjury). A recovery intervention approach sug-gests to clients that they will regain the samemotor performance as they had prior to theproblem and that they will use the same move-ment solutions to the problem. This may be thetype of intervention focus after acute musculo-skeletal injuries. A prevention intervention focusis targeted if secondary complications related tothe identified problem are anticipated and thegoal is to stop these problems from occurring.For example, part of the intervention for a clientafter a stroke with resultant hemiplegia may bean exercise program to prevent further jointcontractures on the involved side. A preventionfocus may also be incorporated with a recoveryintervention to reduce the likelihood of recur-rence of the same problem. We want the studentsto appreciate that all three of these intervention


approaches have equal value and that inter-vention is not always focused solely on a recov-ery strategy.

The presence of contextual factors makes stu-dents consider environmental adaptations aspart of their intervention choices. By using theseterms with ICF terminology, the intent of theintervention is very clear. It also encourages stu-dents to evaluate the relationship between bodyfunctions and structures and activity limitationsand participation restrictions for every client.For example, improving the quadriceps strength(intervention at the component of body function)of the client with osteoarthritis who has dif-ficulty gardening may allow her to get up anddown from kneeling in her garden, but the useof an assistive device (environmental facilitator)such as a low stool for kneeling may achievethe same goal of independence more quickly.The model of parallel interventions would per-mit continued treatment in addition to the assis-tive technology to address the impairment ofdecreased strength (Cook and Hussey, 1995).The use of the ICF terminology and structureallows students to evaluate relationships amongbody structure, function, activities and partici-pation, and environmental factors for each cli-ent. A change at the component of activity caninfluence body functions and structures just as achange at the component of body function maychange activity and participation.

The outcome measures are also classified byICF components. By using ICF terminology forgoal setting, identifying problems and strengthsin the assessment phase, and classifying outcomemeasures, students can determine if the outcomemeasure used to evaluate the result of an inter-vention is measuring the same component thatwas targeted for intervention. For example, ifthe goal of intervention is improved musclestrength (body function), then at least one of theoutcome measures should be a measure of musclestrength (body function). If other goals were ident-ified that targeted different components, thenadditional outcome measures should be used toevaluate changes at this component. For example,if an additional goal of intervention for the gar-dener was the ability to kneel down in her garden,there should be an outcome measure to capturechange in this activity goal.

After evaluation of outcome, the client andtherapist together decide if the goal was

achieved. If the answer is ‘‘yes,’’ then the clientexits the system until a new goal or problem isidentified or continues on a management planto maintain the goal achieved. If the goal hasnot been achieved, then the process is repeatedwith the generation of different hypotheses andintervention strategies. This emphasis on treat-ing problems rather than conditions supportsthe concept that treatment is specific to a prob-lem and is time limited.

The CORxE Clinical Decision-Making Modelis used extensively with the students in the pro-gram as a framework for the identification ofcommon goals in courses in which very differentcontent is taught. Subsequently, we have incor-porated four Integrated Practice courses intoour 28-month program. By using patient scenar-ios, the purpose of these courses is to provide thestudents an opportunity to integrate the clinicalknowledge learned during different courses inthe term and to apply this knowledge in a sys-tematic way through the use of the CORxEClinical Decision-Making Model. Appendix Aprovides an example of a scenario and illustrateshow the Clinical Decision-Making Model is usedto guide learning and evaluation in the inte-grated practice courses.

We have now used both the CORxE Model ofBest Practice and the CORxE Clinical Decision-Making Model in the first year of the MPT pro-gram. The students have grasped the targetedconcepts well, and they have quickly integratedICF philosophy and terminology into their dis-cussions of clients’ problems and physical ther-apy techniques. The CORxE model of bestpractice has reinforced the three tenets of evi-dence-based practice for them, and they realizethat their clinical decisions must consider clientsvalues, therapist knowledge, and informationfrom the research literature. The students arequickly able to distinguish the differencebetween intervention strategies targeted at thecomponents of body function or activity. Theycan also identify if the intervention chosen repre-sented an adaptation or a recovery strategy. Weare excited by the students’ ease in understand-ing and applying these concepts.

The development of models of practice andclinical decision making were important stepsin the development of our master’s entry-levelprogram. They provided a simple, easily under-stood framework for the program and assisted


members of the department to identify and tocommit to essential components of the newcurriculum. They provided a central focus fordecisions concerning course content, structure,and teaching strategies. During sometimesintense discussions regarding the format of thecurriculum, we returned to the Model of BestPractice to guide our decisions. Our experienceshave demonstrated how models can be used tomanage information and knowledge. Ourvision is that the students will use the modelsin the same way to focus and organize theirlearning both in the MPT program and lateras clinical practitioners. We want the studentsto use the models to organize their applicationof specific physical therapy knowledge, skills,and values.

Our long-term goal is that students will usethese models to organize their clinical decision-making as practicing physical therapists. Webelieve that models of practice have an importantrole in clinical practice and could serve many ofthe same purposes for clinicians as they serve inour curriculum. As a profession, we need to dis-cuss and develop models of practice that reflectcontemporary theory, research, and practice.Models are an efficient, organized way to presentand disseminate new ideas and frameworks tothe physical therapy community and to com-municate different clinical approaches. We sug-gest that they are under used in our profession.We have provided in-services to our communityof clinical physical therapists about the back-ground of our two models so that they will befamiliar with the assessment, intervention, andevaluation framework used by the students.Models are powerful tools to advance andexplain our practice, and good models, liketheory, should be continually evaluated andmodified. We look forward to the evolution ofboth our CORxE models.

Acknowledgements

The development of the two models was acollaborative effort of all members of theCurriculum Design Team (CDT). The CDTincluded the Physical Therapy Department staffand representatives from clinical physical thera-pists and from the College of Physical Therapistsof Alberta.

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Appendix A

The information presented in this Appendixillustrates how we have used the CORxE modeland the CORxE Clinical Decision-MakingModel to guide students’ learning and evalu-ation in an example scenario in an IntegratedPractice course.

Orientation to scenario

Following this scenario, the student should beable to confidently and competently assess andtreat a person with hip fracture postsurgically.To achieve that competence, the student willrequire knowledge in all aspects of the ClinicalDecision-Making Model related to the scenario.Below are the topic areas and practical skills(knowledge outcomes) addressed by this scen-ario, arranged in the CORxE model format.

Scenario description

Mrs. Brown is a 75-year-old woman in other-wise good health, who slipped on an icy sidewalkyesterday and fell and broke her hip (neck of thefemur). She was admitted to hospital yesterdayafternoon and had surgery last evening. Thesurgical procedure was an open fixation withAustin Moore prosthesis insertion.

Mrs. Brown is an active woman, who walksher two dogs daily, bowls once a week in asenior’s league, and occasionally looks afterher three grandchildren who live in the samecity. Her 78-year-old husband suffered a strokea few years ago but has recovered quite welland is independent. They live in a 55-year-old,two-bedroom bungalow with steps at the frontof the house. Mrs. Brown’s washer and dryerare down a flight of 12 stairs.

The order from the surgeon is to getMrs. Brown mobile and to commence weightbearing as tolerated. Her expected dischargedate is 3�4 days from now.

Knowledge outcomes organized byCORxE model and CORxE clinicaldecision-making model

Theory

1. Anatomy related to hip fracture2. Austin-Moore surgical procedure including

movement contraindications followingsurgery

3. Total hip replacement surgical procedureincluding movement contraindications fol-lowing surgery

4. Pharmacology related to surgical hipproceduresa. Anticoagulantsb. Pain medications—type and method of

delivery5. Effect (or potential effect) of general anes-

thetic ona. Cardiorespiratory systemb. Cognitive function

6. Hip fracture epidemiology in Canadaa. Introduction to osteoporosis

Assessment

1. Determine assessment plana. What should be assessed from each of the

components?i. Body structureii. Body functioniii.Activityiv. Participationv. Contextual factors

2. Carry out assessment procedures3. On the basis of assessment findings, develop

problem list and treatment goals.

Intervention

1. Treatment (including postsurgical routine)from Day 1 to Discharge (treatment choicejustification and application)

2. Home Exercise Program3. Discharge Teaching

For each treatment suggestion, identify theICF component that it represents.

For each intervention suggestion, identifywhether it represents the expectation of recov-ery, adaptation, or prevention.


Outcome measures

1. Outcome measures (justification of choiceand application) related to:a. Body structureb. Body function (what would you expect

Mrs. Brown to be able to do on discharge?).c. Activityd. Participation

Research

1. Evidence for early mobilization2. Evidence for bed exercises

3. Evidence for longer term (postdischarge)physical training

Evaluation

At the conclusion of the course, the students’learning is evaluated in a group format, as theywork from a patient case example. The followingevaluation form is used and also reflects the inte-gration of the CORxE Clinical Decision-Makingmodel in the evaluation process.

.

Evaluation of individual contributions to the group 1 2 3 4 5 6 7 8

1. Used collaborative skills to move the group forward,(e.g., focus, summarize, check on time, invite participation,work constructively to reach agreement)

2. Contributed information and=or alternative solutions3. Evaluated information=alternatives4. Communicated appropriately, e.g. listened without

interruption, used appropriate tone, showed appropriatenonverbal behavior

Group evaluation

1. Generated appropriate hypothesis re: problem, and ableto discuss possible differential diagnosis

0 1 2 3 4

2. Developed appropriate, effective assessment plan to rulein or rule out hypotheses.

0 1 2 3 4

3. Developed appropriate problem and goal list, using ICFterminology.

0 1 2 3 4

4. Able to identify positive and negative influences on thepresenting problem

0 1 2 3 4

5. Able to develop appropriate treatment plan (3 itemsmaximum), and classify by ICF components

0 1 2 3 4

6. Identified that treatment was at the level of adaptation,prevention or recovery

0 1 2 3 4

7. Identified appropriate outcome measures, in relation togoals and treatment strategies, and classified by ICF

0 1 2 3 4

8. Considered contextual factors and their positive andnegative influences on assessment, treatment and out-comes.

0 1 2 3 4

9. Included client in all components of clinical decision-making process

0 1 2 3 4

(Continued)


(continued )

Group Evaluation

10. Demonstrates evidence based practice throughout(incorporates patient values, clinical experience andresearch)

0 1 2 3 4

11. Incorporated research findings effectively in assessment,treatment, and outcome measure decisions

0 1 2 3 4

12. Demonstrated understanding of interdependence oftheory, research and practice in group discussions.

0 1 2 3 4

13. Used time effectively: stayed on task 0 1 2 3 4

All items (including individual) will be graded on a 0�4 scale. If students receive gradeof 2 or below, please provide written explanation.

0 ¼ unacceptable 1 ¼ borderlineunacceptablebehavioror outcome

2 ¼ borderlineacceptablebehavioror outcome

3 ¼ expectedbehavioror outcome(met standard)

4 ¼ aboveexpectedbehavioror outcome
