It has been postulated that occupational therapists when choosing an appropriate intervention method, use theoretical and practical knowledge (factors), based upon identifying client's goals to guide their clinical reasoning. The overall aim of this study was to identify factors and their relative contributions to the decisions occupational therapists make in the management of upper limb (UL) hypertonicity of children and adolescents with cerebral palsy (CP). Studies about general factors which influence occupational therapists' decision making have been addressed widely in the literature. However, studying influential factors in specific areas such as in the management of UL hypertonicity of clients with CP is limited. The information obtained from studies of decision making with other client groups can not readily be generalised as it has been demonstrated that specific task characteristics induce different types of cognitive thinking. For example, working with clients with orthopaedic problems may induce logical thinking, while practicing with clients with neurological problems promotes intuitive thinking. The management of UL hypertonicity of clients with CP was chosen as the focus of this study for two main reasons. First, the incidence of CP is high, manifesting in between 1.4 and 2.4 of 1000 live births. Second, people with CP are one of the major client groups referred to occupational therapy (OT) clinics as outpatients. The literature reviewed highlighted a lack of evidence about what therapists attend to when making decisions about the management of UL hypertonicity for clients with CP. To identify and evaluate these factors, the current research employed Social Judgment Theory (SJT). This methodology was selected because it had the capacity to access intuitive thought or tacit knowledge that is very difficult for experienced therapists to explain. Furthermore, SJT is most relevant in situations where there is no optimal decision. The current study proceeded in five phases. Phases One to Three were conducted to identify the most relevant factors to be used in the case vignettes necessary for the application of SJT. This process involved a review of the literature, consultation with clinical experts and then involved twelve experienced therapists in a process of identifying, refining, and ranking the relevant factors in order of priority. As a result of the processes in Phases One to Three 37 factors and their ranked importance were identified. The identified factors were reduced from 37 to 12 on the basis of ranking, cluster analysis and consultation with experts and appropriate scales identified for their measurement. These factors formed the basis of Phase Four of this study. In Phase Four 10 sample case vignettes as well as an administration manual were developed and four therapists were asked to make decisions for these cases. On the basis of therapists' comments, some changes were made in case vignettes and administration manual. Finally, 110 case vignettes were generated randomly (20 were repeated to examine consistency) for Phase Five of the study. In Phase Five, eighteen occupational therapists (16 females and 2 males), mean age of 36.7 years (SD = 7.6 years) who had worked with people with CP for a mean of 10.4 years (SD = 6.0 years) made decisions for the generated case vignettes. The findings of Phase Five revealed that therapists used three factors mainly in their decisions including severity of spasticity, wrist and finger posture, and client and family background. They had poor insight into their decision making (r = 0.36) and demonstrated only moderate consistency (r = 0.46). When therapists were divided into two groups based on their level of performance in respect to therapists' consistency and their ability to discriminate between cases, both groups used severity of spasticity and wrist and finger posture in their decision making. However, the higher performing group used limitation in passive range of movement and previous intervention in their decision making, and the low performing group used client and family background.

Problem-solving and integration of knowledge are key objectives of the undergraduate dental curriculum of the School of Dentistry, University of Pretoria, which aims to develop the clinical reasoning skills of students. For practical reasons the School provides discipline-based teaching and learning, which, according to the literature, might limit a student’s ability to integrate knowledge during clinical reasoning processes. The literature suggests that problem-solving by means of case studies – an active teaching and learning strategy– might be a useful method to develop and integrate knowledge at undergraduate level, and that earlier exposure to clinical cases might assist in the attainment of clinical reasoning skills at an earlier stage. Hence, this action research study describes the planning, design, implementation and evaluation of a “new” Comprehensive Patient Care curriculum over a three-year period (2009 - 2011) based on Kern’s “six-step approach to curriculum development”. The new curriculum employs an adjunctive integrated case-based approach according to the principles described in the “Four Component Instructional Design Model” and a new variant of the so-called “progress test”, starting already in the preclinical (third) year of study, to develop and test students’ clinical reasoning skills over time. The exit-level progress test results of dental students who had been taught by following an adjunctive integrated case-based approach were statistically analysed, using mixed model statistics, and were compared with the clinical decision-making skills of cohorts who had been taught by following the traditional discipline-based approach. These analyses were complemented by bivariate and multivariate quantitative analyses and qualitative student feedback (mixed methods). The validity of the progress test results was also examined by comparing the results of different cohorts. The fifth-year cohort who had been exposed to integrated case-based teaching and learning from their preclinical year performed significantly better in the progress test at exit level than the cohorts who had received only discipline-based teaching and learning, even when controlling for previous academic performance. These findings were supported by the quantitative and qualitative feedback that students gave about the educational processes that were followed. The progress test performed reasonably well as a measurement tool and all the differences that were measured between the different cohorts could be explained logically. Case specificity posed the biggest threat to the reliability of the test. The results suggest that integrated case-based teaching and learning, commencing in the preclinical study years, might be a useful intervention to improve clinical reasoning ability at exit level in dental schools such as the School of Dentistry, University of Pretoria that follow a discipline-based approach. The results of this action research study provided particularly useful information, which will allow further improvements to the educational intervention. The results of this study require further research to substantiate the findings beyond doubt. / Thesis (PhD)--University of Pretoria, 2013. / gm2014 / Dental Management Sciences / unrestricted

No description available.

Indiana University-Purdue University Indianapolis (IUPUI) / It is unknown whether timing of human patient simulation (HPS) in a semester, demographic (age, gender, and ethnicity), and situational (type of program and previous baccalaureate degree and experience in healthcare) variables affects students’ perceptions of their clinical reasoning abilities. Nursing students were divided into two groups, mid and end of semester HPS experiences. Students’ perceptions of clinical reasoning abilities were measured at Baseline (beginning of semester) and Time 2 (end of semester), along with demographic and situational variables. Dependent variable was Difference scores where Baseline scores were subtracted from Time 2 scores to reveal changes in students’ perceptions of clinical reasoning. Students who were older and had previous healthcare experience had higher scores, as well as students in the AS program, indicating larger changes in students’ perceptions of clinical reasoning abilities from Baseline to Time 2. Timing of HPS, mid or end of semester, had no effect on Difference scores, and thus students’ perceptions of clinical reasoning abilities.

The purpose of this study was primarily to explore the conceptualization of critical thinking development in radiologic science students by radiography program directors. Seven research questions framed three overriding themes including 1) perceived definition of and skills associated with critical thinking; 2) effectiveness and utilization of teaching strategies for the development of critical thinking; and 3) appropriateness and utilization of specific assessment measures for documenting critical thinking development. The population for this study included program directors for all JRCERT accredited radiography programs in the United States. Questionnaires were distributed via Survey Monkey©, a commercial on-line survey tool to 620 programs. A forty-seven percent (n = 295) response rate was achieved and included good representation from each of the three recognized program levels (AS, BS and certificate). Statistical analyses performed on the collected data included descriptive analyses (median, mean and standard deviation) to ascertain overall perceptions of the definition of critical thinking; levels of agreement regarding the effectiveness of listed teaching strategies and assessment measures; and the degree of utilization of the same teaching strategies and assessment measures. Chi squared analyses were conducted to identify differences within each of these themes between various program levels and/or between program directors with various levels of educational preparation as defined by the highest degree earned. Results showed that program directors had a broad and somewhat ambiguous perception of the definition of critical thinking, which included many related cognitive processes that were not always classified as attributes of critical thinking according to the literature, but were consistent with definitions and attributes identified as critical thinking by other allied health professions. These common attributes included creative thinking, decision making, problem solving and clinical reasoning as well as other high-order thinking activities such as reflection, judging and reasoning deductively and inductively. Statistically significant differences were identified for some items based on program level and for one item based on program director highest degree. There was general agreement regarding the appropriateness of specific teaching strategies also supported by the literature with the exception of on-line discussions and portfolios. The most highly used teaching strategies reported were not completely congruent with the literature and included traditional lectures with in-class discussions and high-order multiple choice test items. Significant differences between program levels were identified for only two items. The most highly used assessment measures included clinical competency results, employer surveys, image critique performance, specific course assignments, student surveys and ARRT exam results. Only one variable showed significant differences between programs at various academic levels.

För att kunna ge vård av säker och god kvalitet krävs att sjuksköterskor har kunskap inom många områden, eftersom de har ansvar för såväl bedömning, planering och genomförande, som utvärdering och dokumentation av omvårdnadsarbetet. Ett av flera ansvarsområden för sjuksköterskor i deras dagliga arbete är beslutsfattande om insättning och skötsel av perifera venkatetrar (PVK). En PVK är en tunn plastkateter som sätts in i ett blodkärl via en kanyl. PVK används vid intravenös behandling med till exempel antibiotika och andra läkemedel, blodkomponenter eller näringslösningar. En stor andel av alla patienter inom hälsooch sjukvård kommer någon gång i kontakt med en PVK och riskerar då också att utsättas för komplikationer. En vanlig komplikation i samband med PVK är tromboflebit. Tromboflebit förekommer i olika svårighetsgrader och innebär att inflammation har uppstått i blodkärlet i kombination med samtidig blodpropp. Symtom som kan uppstå är rodnad, svullnad, smärta, hårdhet i kärlet och varig infektion. Det finns kliniska riktlinjer om PVK framtagna både på nationell och på lokal nivå som fungerar som ett stöd i beslutsfattandet. Tidigare forskning har visat att kliniskt verksamma ibland inte följer riktlinjer. Anledningar till att inte riktlinjer följs kan till exempel vara att de kliniskt verksamma inte håller med om det som rekommenderas, inte känner till rekommendationerna, inte har tid eller möjlighet att påverka de beslut som fattas eller att det finns individuella faktorer att ta hänsyn till för den enskilda patienten. 52 Frågan kan ställas om sjuksköterskor använder sig av kliniska riktlinjer i sitt dagliga arbete eller om det är andra faktorer och aspekter som har betydelse och påverkar beslutsfattandet. Denna licentiatavhandling syftade till att beskriva sjuksköterskors kliniska beslutsfattande genom att fokusera på deras följsamhet till riktlinjer och beslutsresonemang om PVK. Två studier har genomförts inom ramen för denna licentiatavhandling. Studie I undersökte i vilken utsträckning sjuksköterskor följer nationella och lokala riktlinjer om PVK. PVKns placering och storlek, tiden som PVKn varit placerad i blodkärlet, dokumentation vid PVKns förband samt om det fanns tecken på tromboflebit vid PVKn var variabler som undersöktes i relation till de rekommendationer som fanns. Utifrån två protokoll samlades strukturerad data in och analyserades. Totalt 343 PVK ingick i analysen. I studie II undersöktes de tecken och påverkande faktorer som har betydelse när sjuksköterskor fattar beslut om skötsel av PVK. I studien observerades 43 sjuksköterskor i sitt dagliga arbete. Sjuksköterskorna intervjuades också dels om PVK-besluten som de fattade under observationerna, dels om deras beslutsfattande om PVK-skötsel i allmänhet. Studie I visade att sjuksköterskor delvis följer riktlinjer. Det fanns skillnader mellan de vårdavdelningar som hade nationella riktlinjer och de som hade lokala riktlinjer, i hur de olika avdelningarna valde placering, storlek och dokumenterade vid PVKns förband. PVKn hade suttit längre tid än rekommenderat i varierande utsträckning. Andelen tromboflebiter var låg (7.0%) och tromboflebiterna var milda. Det tyder på att sjuksköterskor är noga med att ta bort PVK vid tecken på komplikationer. Studie II visade att sjuksköterskor i sitt kliniska resonemang om PVK-skötsel tar hänsyn till den individuella patientsituationen, sjuksköterskans arbetssituation och erfarenhet av PVK-skötsel. Det framkom även att sjuksköterskor balanserar mellan att undvika eller minimera obehag och smärta för patienten och samtidigt förebygga komplikationer från PVKn. Resultaten från denna licentiatavhandling kan få betydelse för undervisning av sjuksköterskestudenter och även när kliniska riktlinjer ska införas på vårdavdelningar. / Every working shift nurses make several decisions, including decisions about management of peripheral venous catheters (PVC). Peripheral catheterisation is a common procedure, which affects numerous patients in health care today. PVC are for example used for intravenous infusions with antibiotics, nutrients and blood components. Having PVC in situ may lead to complications such as thrombophlebitis. Clinical guidelines have been developed within the area to assist nurses in their decision-making, but clinical guidelines are not always adhered to. There are several reasons why clinicians do not always adhere to clinical guidelines, although such adherence may lead to fewer complications. Choices for decisions regarding PVC management have been investigated in previous studies, but not in a naturalistic setting. The overall aim of this licentiate thesis was to describe nurses’ clinical decision-making through focusing on their adherence to clinical guidelines and their clinical reasoning concerning decisions of PVC. Two studies have been conducted and data were collected during a six-month period, from December 2004 to June 2005. Study I investigated nurses’ adherence to national and local PVC guidelines by focusing on time in situ, site, size and documentation at the dressing. The thrombophlebitis frequency associated with PVC in situ was also investigated. Structured observations through two protocols were carried out and data about 343 PVC were analysed. Study II investigated nurses’ clinical reasoning regarding PVC management and cues and factors of importance in the decision10 making process were analysed. Nurses were observed in their daily work with focus on PVC management. They were interviewed both about the PVC decisions made in the observed situations and about factors influencing their reasoning regarding PVC management in general. The observations facilitated the interviews. Transcribed interview texts were analysed with content analysis. The results in study I showed that thrombophlebitis frequency was 7.0% and the nurses seemed to replace or remove PVC before any severe complications arose in accordance with clinical guidelines. Nurses partly adhered to national and local guidelines concerning site, size, documentation at the dressing and time in situ. Differences in guideline adherence were observed for wards with local or national guidelines, as well as for wards with different specialities. The results indicate that local guidelines may have an impact on guideline adherence but these results need further exploration. Analysis of interview texts in study II resulted in a category system with three main categories describing cues and factors of importance in the nurses’ clinical reasoning about PVC: the individual patient situation, the nurse’s work situation, and experience of PVC management. An overall theme was also revealed in the interview texts and the nurses balance in their clinical reasoning between avoiding or minimizing discomfort and pain for the patient and preventing complications from the PVC. The results from this licentiate thesis have implications for the education of nurses as well as during implementation of clinical guidelines. / <p>Note: The papers are not included in the fulltext online.</p><p>Paper I in thesis as accepted manuscript, paper II as manuscript.</p><p></p>

Introduction: Ethical decision-making is an important component of occupational therapy practice in Canada. Research is needed to understand ethical decision-making and how to build occupational therapists’ competency to make ethical decisions. Purpose: The aim of this thesis was to study ethical decision-making in occupational therapy practice in order to contribute to epistemological development regarding ethics in occupational therapy and to support continuing competency in ethical decision-making. Method: Three studies comprise this thesis. A constructivist grounded theory study was conducted involving in-depth semi-structured interviews with 18 occupational therapists from a range of practice settings to explore the process of ethical decision-making. An interpretive description study using secondary analysis of grounded theory data was conducted to explore gaps related to continuing competency in ethical decision-making from the participants’ perspective and to generate recommendations for future directions to support continuing competency. Finally, a non-randomized, single-group, pre- and post-test study (n=33) was conducted to evaluate an on-line education module developed to support competency for clinician-educators. Findings: The grounded theory study led to development of an ethical decision-making prism capturing three processes: Considering the Fundamental Checklist, Consulting Others, and Doing What’s Right. The interpretive description study highlighted two gaps related to continuing competency in ethical decision-making: lack of knowledge and lack of supports. Education, tool development, and ethics mentorship were identified directions for development. The third evaluation study found that an on-line education module led to improvements in ethics knowledge and intent to change practice but not to actual practice change. Implications: This thesis advances a theoretical understanding of ethical decision-making in occupational therapy practice and an applied understanding of occupational therapists’ needs related to competent ethical decision-making. Findings also provide preliminary data regarding on-line ethics education to advance knowledge and skills of clinician-educators who are involved in cultivating ethical decision-making among student occupational therapists. / Thesis / Doctor of Philosophy (PhD) / “Doing what’s right”, or ethical decision-making, is an important part of being an occupational therapist in Canada. To help occupational therapists build knowledge and skills it is important to understand how they make ethical decisions in day-to-day practice. This PhD describes three studies that look at three different aspects of ethical decision-making. The first study presents a theoretical explanation of how occupational therapists decide what’s right to do. The second study uses the same data to look at supports that occupational therapists feel they need to build knowledge and skills about ethical decision-making. The third study measures the value of an on-line education course in helping occupational therapy educators teach students about ethical decision-making. Results of these studies can be used to support occupational therapists in doing what’s right. Results also highlight areas for additional study to further support ethical occupational therapy practice in Canada.

La pratique de l’hématologie, comme celle de toute profession, implique l’acquisition d’un raisonnement adéquat. Se basant sur une théorie de psychologie cognitive, le test de concordance de script (TCS) a été développé et validé comme un instrument permettant d’évaluer le raisonnement clinique dans diverses spécialités médicales. Le but de cette étude était d’examiner l’utilité et les paramètres psychométriques d’un TCS en hématologie. Nous avons construit un TCS composé de 60 questions que nous avons administré à 15 résidents juniors (R1 à R3 en médecine interne), 46 résidents séniors (R4, R5 et R6 en hématologie) et 17 hématologues à travers le Canada. Après optimisation, le TCS comptait 51 questions. Sa consistance interne mesurée par le coefficient de Cronbach alpha était 0.83. Le test était en mesure de discriminer entre les résidents selon leur niveau de formation. Les questions contenant des images (n=10) semblaient avoir un potentiel discriminatoire plus élevé. Les scores obtenus par les résidents séniors corrélaient modéremment avec ceux obtenus à un test conventionnel d’hématologie composé de questions à choix multiples et à courte réponse (r de Pearson = 0.42; p=0.02). Le TCS a été complété en 36 minutes en moyenne et a été bien reçu par les participants. Le TCS est un instrument d’évaluation utile et valide en hématologie. Il peut être utilisé à des fins formatives en aidant au suivi de la progression des résidents. Il pourrait aussi être combiné à d’autres instruments d’évaluation à des fins sanctionnelles, ou encore, en éducation médicale continue. / The practice of hematology, like any other profession, requires the acquisition of adequate judgment. Based on cognitive psychology theory, the script concordance test (SCT) has been developed and validated as an instrument capable of evaluation clinical judgement in various medical specialties. The goal of this study was to examine the usefulness and the psychometric qualities of the SCT in hematology. We constructed a SCT composed of 60 questions and we administered it to 15 junior residents (R1 to R3 in internal medicine), 46 senior residents (R4, R5 and R6) and 17 hematologists from across Canada. After item optimization, the test comprised 51 questions. Its internal consistency measured by Cronbach alpha was 0.83. The test was able to discriminate between residents according to their year of training. Questions containing an image (n=10) seemed to offer a stronger discriminative potential. Scores obtained by the senior residents correlated moderately with those obtained on a conventional hematology exam made of multiple choice questions and short-answers (Pearson r: 0.42; p=0.02). The SCT was completed in an average of 36 minutes and was well received by participants. The SCT is a useful and valid evaluation instrument in hematology. It may be used during training to monitor resident progression. It may also be combined to other evaluation tools and used for summative purposes or in continuing medical education.

Esta pesquisa teve como finalidade permitir a expressão das características do diagnosticador, a fim de que ele próprio reconhecesse como suas características pessoais influenciam suas decisões clínicas. OBJETIVOS: Testar um programa de formação permanente, baseado em histórias de vida, para o aprimoramento do raciocínio clínico em enfermagem; descrever os temas presentes nos processos cognitivos e metacognitivos dos participantes, desencadeados pelas estratégias do programa; analisar a influência das estratégias do programa sobre o raciocínio clínico dos participantes; descrever as intervenções realizadas pelas pesquisadoras. MÉTODO: Planejamento e execução de pesquisa-formação em três hospitais e uma escola de enfermagem de São Paulo, Brasil. Os dados foram constituídos pelas produções escritas dos participantes e pelas observações das pesquisadoras, anotadas em diário. Esses dados foram interpretados a partir da análise de seus conteúdos, com base em proposições teóricas sobre raciocínio clínico e sobre histórias de vida e formação. RESULTADOS: O programa foi implementado com um grupo de 7 enfermeiras de um hospital geral universitário e com dois grupos (um com 7 e outro com 6) de estudantes de graduação em enfermagem. Nos três grupos houve 8 encontros semanais em que ocorreram análises de textos, avaliações de saúde, estudos de caso de pacientes, escritas e partilhas das histórias de vida e projetos. Os temas recuperados com o programa referiram-se aos domínios afetivo e cognitivo. As participantes realizaram e refletiram sobre a coleta e interpretação de informações, elaboraram julgamentos clínicos, analisaram dilemas ético-morais e significados sobre o cuidado de si e dos outros. CONCLUSÕES: As reflexões sobre o autocuidado e as próprias histórias de vida (cuidado de si) permitiram às participantes reavivarem as múltiplas influências que as formam, e que formam os outros, e dinamizaram conhecimentos, habilidades e atitudes necessárias em suas relações com os usuários do sistema de saúde, colegas de trabalho e profissão (cuidado de outros) / The present study intended to enable the expression of the characteristics of diagnosing professionals, so that they could acknowledge to what extent personal characteristics could influence their clinical decisions. OBJECTIVES: To test a program of permanent training, based on life histories, to improve clinical reasoning in nursing; to describe the topics present in cognitive and metacognitive processes of participants, triggered by program strategies; to analyze the influence of program strategies over clinical reasoning of participants; to describe the interventions used by the researchers. METHOD: Planning and execution of the research program and training in three hospitals and one nursing school in Sao Paulo, Brazil. Data consisted of the writing productions of participants and the observations of the researchers, registered in diaries. Data were interpreted by analyzing the content based on theoretical assumptions about clinical reasoning and life histories and training. RESULTS: The program was implemented in a group of 7 nurses in a general university hospital and in two groups (7 and 6 members, respectively) of undergraduate nursing students. The three groups had 8 weekly meetings where they analyzed texts, healthcare examinations, case studies, written pieces and shared life histories and projects. The topics retrieved by the program comprised the affective and cognitive domains. Participants performed and reflected about the collection and interpretation of information, made clinical judgments, analyzed ethical-moral dilemmas, and the meanings of taking care of others and of themselves. CONCLUSIONS: Reflections about self-care and their own life histories (taking care of themselves) enabled the participants to revive the multiple influences that had formed them and had formed the others. They could maximize knowledge, skills and attitudes required to their relationships with healthcare users, co-workers and the profession (taking care of the others)

Sammanfattning Syfte: Syftet med studien var att beskriva arbetsterapeuters kliniska resonemang samt erfarenheter av interventioner för att främja delaktighet i aktivitet hos barn med ADHD. Metod: Studien var baserad på en kvalitativ ansats med semistrukturerade intervjuer för att undersöka arbetsterapeuternas kliniska resonemang och erfarenheter. Sex arbetsterapeuter från olika regioner i Sverige deltog i studien. En kvalitativ innehållsanalys användes för att undersöka erfarenheter av interventioner vilka därefter analyserades deduktivt för att identifiera kliniska resonmang. Resultat: Resultatet redovisades i ett övergripande tema; Att möta barnet och familjen i den aktuella situationen med tre kategorier; Hela familjen som klient, Kartläggning av aktivitetsutförande för en lyckad intervention och Resonemang kring yrkesetiska aspekter. Resultatet visade att klientcentrering var kärnan i deltagarnas kliniska resonemang där empati, samarbete och kommunikation var viktiga aspekter att resonera kring. Deltagarnas erfarenhet var att det mest betydelsefulla för att främja delaktighet i aktivitet hos barn med ADHD var inlärning av strategier för att hantera barnets begränsningar i vardagen. Utöver det var olika former av kognitivt stöd vanligt förekommande interventioner. Slutsats: Studien har bidragit till ökad insikt i arbetsterapeuters erfarenhet av interventioner i arbetet med barn med ADHD samt en ökad förståelse för arbetsterapeuters kliniska resonemang.