Masters Research - Master of Medical Science / Pattern recognition is a non-analytical clinical reasoning process which has been reported in the medical and allied health literature for some time. At a time when clinical problem solving was largely considered to consist of the analytical process of hypothetico-deductive reasoning, pattern recognition was introduced in the literature with observations of greater efficiency and accuracy. The research that followed these apparent opposing models of clinical reasoning resulted in significant growth in the understanding of problem solving in healthcare. On commencing this thesis the knowledge surrounding pattern recognition in physiotherapy was insufficient for its inclusion in educational design. Consequently the aims of the study described in this thesis were to clearly identify pattern recognition using high fidelity case methods and observe its relationship with accuracy and efficiency. The study utilised a single case study with multiple participants. A real clinical case with a diagnosis of high grade lumbar spine spondylolisthesis was simulated using a trained actor. This provided a high fidelity case study method allowing the observation of more realistic problem solving practices as compared with the common low fidelity paper case approach. Two participant groups were included in the study to investigate the common belief that pattern recognition is an experience based reasoning process. The expert group comprised ten titled musculoskeletal physiotherapists with a minimum of ten years overall clinical experience and greater than two years experience following the completion of postgraduate study. The novice group included nine physiotherapists in their first year of clinical practice following completion of an undergraduate degree. Qualitative data collection methods included observation of the participant taking a patient history of the simulated client and a stimulated retrospective recall interview with the participant. The mixed method analysis used in the study provided methodological triangulation of the results and supported the presence of pattern recognition in musculoskeletal physiotherapy. The quantitative research findings indicated that pattern recognition was significantly more likely to produce an accurate diagnostic outcome than analytical reasoning strategies during a physiotherapy history. However its use was not a guarantee of success with only three of the four experts using pattern recognition identifying the correct diagnosis. Although four experts utilised pattern recognition as compared with only one novice, no significant overall differences were found in the use of pattern recognition between the expert and novice participant groups. The findings relating to time data found that expert participants took longer to conduct the client history than novices. Similarly those participants identified using pattern recognition also required more time which seemingly contradicts the view of pattern recognition being an efficient clinical reasoning process. This finding was limited by the incomplete nature of the study which did not include a physical examination or any client management.

Doctor of Philosophy (PhD) / Effective clinical reasoning and its communication are essential to health professional practice, especially in the current health care climate. Increasing litigation leading to legal requirements for comprehensive, relevant and appropriate information exchange between health professionals and patients (including their caregivers) and the drive for active consumer involvement are two key factors that underline the importance of clear communication and collaborative decision making. Health professionals are accountable for their decisions and service provision to various stakeholders, including patients, health sector managers, policy-makers and colleagues. An important aspect of this accountability is the ability to clearly articulate and justify management decisions. Considerable research across the health disciplines has investigated the nature of clinical reasoning and its relationship with knowledge and expertise. However, physiotherapy research literature to date has not specifically addressed the interaction between communication and clinical reasoning in practice, neither has it explored modes and patterns of learning that facilitate the acquisition of this complex skill. The purpose of this research was to contribute to the profession’s knowledge base a greater understanding of how experienced physiotherapists having learned to reason, then learn to communicate their clinical reasoning with patients and with novice physiotherapists. Informed by the interpretive paradigm, a hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants’ learning journeys were diverse, although certain factors and episodes of learning were common or similar. Participation with colleagues, peers and students, where the participants felt supported and guided in their learning, was a powerful way to learn to reason and to communicate reasoning. Experiential learning strategies, such as guidance, observation, discussion and feedback were found to be effective in enhancing learning of clinical reasoning and its communication. The cultural and environmental context created and supported by the practice community (which includes health professionals, patients and caregivers) was found to influence the participants’ learning of clinical reasoning and its communication. Participants reported various incidents that raised their awareness of their reasoning and communication abilities, such as teaching students on clinical placements, and informal discussions with peers about patients; these were linked with periods of steep learning of both abilities. Findings from this research present learning to reason and to communicate reasoning as journeys of professional socialisation that evolve through higher education and in the workplace. A key finding that supports this view is that clinical reasoning and its communication are embedded in the context of professional practice and therefore are best learned in this context of becoming, and developing as, a member of the profession. Communication of clinical reasoning was found to be both an inherent part of reasoning and an essential and complementary skill necessary for sound reasoning, that was embedded in the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined and should be learned concurrently. The learning and teaching of clinical reasoning and its communication should be synergistic and integrated; contextual, meaningful and reflexive.

Doctor of Philosophy (PhD) / Effective clinical reasoning and its communication are essential to health professional practice, especially in the current health care climate. Increasing litigation leading to legal requirements for comprehensive, relevant and appropriate information exchange between health professionals and patients (including their caregivers) and the drive for active consumer involvement are two key factors that underline the importance of clear communication and collaborative decision making. Health professionals are accountable for their decisions and service provision to various stakeholders, including patients, health sector managers, policy-makers and colleagues. An important aspect of this accountability is the ability to clearly articulate and justify management decisions. Considerable research across the health disciplines has investigated the nature of clinical reasoning and its relationship with knowledge and expertise. However, physiotherapy research literature to date has not specifically addressed the interaction between communication and clinical reasoning in practice, neither has it explored modes and patterns of learning that facilitate the acquisition of this complex skill. The purpose of this research was to contribute to the profession’s knowledge base a greater understanding of how experienced physiotherapists having learned to reason, then learn to communicate their clinical reasoning with patients and with novice physiotherapists. Informed by the interpretive paradigm, a hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants’ learning journeys were diverse, although certain factors and episodes of learning were common or similar. Participation with colleagues, peers and students, where the participants felt supported and guided in their learning, was a powerful way to learn to reason and to communicate reasoning. Experiential learning strategies, such as guidance, observation, discussion and feedback were found to be effective in enhancing learning of clinical reasoning and its communication. The cultural and environmental context created and supported by the practice community (which includes health professionals, patients and caregivers) was found to influence the participants’ learning of clinical reasoning and its communication. Participants reported various incidents that raised their awareness of their reasoning and communication abilities, such as teaching students on clinical placements, and informal discussions with peers about patients; these were linked with periods of steep learning of both abilities. Findings from this research present learning to reason and to communicate reasoning as journeys of professional socialisation that evolve through higher education and in the workplace. A key finding that supports this view is that clinical reasoning and its communication are embedded in the context of professional practice and therefore are best learned in this context of becoming, and developing as, a member of the profession. Communication of clinical reasoning was found to be both an inherent part of reasoning and an essential and complementary skill necessary for sound reasoning, that was embedded in the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined and should be learned concurrently. The learning and teaching of clinical reasoning and its communication should be synergistic and integrated; contextual, meaningful and reflexive.

The prescribing rights of non-medical healthcare professionals in the United Kingdom (UK) are some of the most extensive in western medical practice. Nurses, pharmacists, physiotherapists, optometrists, chiropodists, podiatrists, therapeutic and diagnostic radiographers and dieticians, with appropriate training have the authority to prescribe. They are often referred to as non-medical prescribers (NMPs). These non-medical healthcare professionals should have a specified number of years of post-registration experience in order to undertake specific training in prescribing. There has been a limited amount of research exploring how non-medical healthcare professionals acquire their expertise during the prescribing programme. In addition, there is a gap in the literature on how NMPs apply their acquired expertise during the process of making clinical prescribing decisions. A programme of research was conducted to explore the learning processes and decision-making skills of pharmacist and nurse independent prescribers working in secondary care. The research used current literature on pharmacist and nurse independent prescribing by conducting a systematic review to assess how their expertise development is reported in the literature. In addition, the learning experiences of secondary care pharmacists and nurses undertaking the independent prescribing programme was explored by employing a novel audio-diary technique followed by semi-structured interviews on 7 nurses and 6 pharmacists. Students were mainly recruited via their non-medical prescribing programme leaders at a number of accredited universities across the UK. There was little opportunity in this study to explore the clinical reasoning processes of students as they were learning to prescribe. Therefore, the final study aimed to explore how secondary care pharmacist and nurse independent prescribers make clinical prescribing decisions. A total of 21 independent prescribers working in secondary care took part in this study, mainly recruited via their non-medical prescribing lead and social media. This study employed a think-aloud protocol method using validated clinical vignettes followed by semi-structured interviews. Students and NMPs occupied a wide range of roles. Ethical approval from the University of Manchester Research Ethics Committee (UREC) and governance approvals from a number of National Health Service (NHS) hospitals were obtained before conducting the research. NMPs were influenced by a number of intrinsic and extrinsic factors during the process of learning to prescribe and when making prescribing decisions. Students also experienced an affective phase of transition in which students became highly metacognitive as they began to form their identities as prescribers and reflect on their confidence and competence. There were notable differences between how pharmacists and nurses learned to prescribe, which were also seen during the process of clinical decision-making as independent prescribers. Despite this, pharmacists and nurses revealed a similar pattern in their decision-making processes as prescribers. Findings from this programme of research provide further insight into the specific training and support requirements of these healthcare professionals. Additional research with NMPs would be beneficial to contribute to the currently limited understanding of the learning and clinical reasoning processes of NMPs.

Introdução: O Test de Concordance de Scripts (TCS) é uma ferramenta de avaliação projetada para medir o raciocínio clínico em situações de incerteza. O Test de Concordance de Scripts Human Caring (TCSHC) foi desenvolvido no Canadá com base na teoria de scripts e orientado pelo modelo do Cuidado Humano de Jean Watson. Dispor de um instrumento de avaliação do raciocínio clínico como o Test de Concordance de Scripts Human Caring - versão brasileira será contribuição relevante para o desenvolvimento de pesquisas sobre o raciocínio clínico na enfermagem. Objetivos: Adaptar culturalmente e validar o Test de Concordance de Scripts Human Caring (TCSHC) para o Brasil; estimar as propriedades psicométricas da versão brasileira do TCSHC; avaliar o raciocínio clínico de enfermeiros e estudantes de enfermagem; testar associações entre raciocínio clínico e variáveis demográficas, de formação e relacionadas à experiência clínica. Métodos: A adaptação para o português do Brasil foi realizada por tradução e back-translation conforme diretrizes reconhecidas, e a grade de pontuação foi criada com as respostas de 20 especialistas. Respostas de 644 participantes (idade média= 36,9 anos; DP=9,0, 348/54,03% estudantes de enfermagem e 296/45,96% enfermeiros) ao TCSHC versão brasileira foram submetidas a análises de associação, de consistência interna, e fatorial confirmatória e exploratória. Resultados: Os 92 itens e as instruções do TCSHC foram adaptados para o Brasil. Dos 92 itens, foram excluídos 39 por correlação item-total <0,2. O TCSHC versão brasileira ficou constituído por 53 itens, com alfa de Cronbach de 0,87. Análises fatoriais confirmatória e exploratória não identificaram estrutura teórica ou estrutura interpretável para os 53 itens. Os escores médios no TCSHC dos especialistas, enfermeiros e estudantes foram diferentes (F=12,135; p=0,000); especialistas obtiveram melhores escores que os enfermeiros (p=0,021) e que os estudantes (p=0,021) e os enfermeiros melhores escores que os estudantes (p=0,001) evidenciando a validade discriminante do TCSHC versão brasileira. Houve associação entre raciocínio clínico e sexo (mulheres com escores mais altos que os homens; t=-3,33; p=0,001); alunos expostos ao processo de enfermagem apresentaram melhores escores que os não expostos (t=-2,72; p=0,007); entre os enfermeiros houve associação entre o maior grau de formação e raciocínio clínico (F=4,772; p=0,003; doutorado > especialização (p=0,002) e > graduação (p=0,033). Não houve correlação do raciocínio clínico com o tempo de experiência profissional entre os enfermeiros (r=0,158; p=0,006) e nem com a fase da graduação atual dos estudantes (r=0,144; p=0,007). Conclusão: O TCSHC versão brasileira apresentou evidências de confiabilidade satisfatória, com boa medida de validade discriminante. Quanto a validade de construto não foi possível confirmar a estrutura teórica proposta para o instrumento original, tampouco identificar estrutura interpretável. / Introduction: The Script Concordance Test (SCT) is an assessment tool designed to measure clinical reasoning in situations of uncertainty. The Concordance test of Human Caring Scripts (TCSHC) was developed in Canada based on scripts theory and guided by Jean Watson\'s Human Care model. Having such an instrument to evaluate clinical reasoning such as the Concordance Test of Human Caring Scripts - in a Brazilian version will be a relevant contribution for the development of research on clinical reasoning in nursing. Objectives: To culturally adapt and validate the Concordance Test of Human Caring Scripts (TCSHC) for Brazil; to estimate the psychometric properties of the Brazilian version of the TCSHC; to evaluate the clinical reasoning of nurses and nursing students; to test associations between clinical reasoning and demographic, training, and clinical experience variables. Methods: The adaptation to Brazilian Portuguese was performed by translation and back-translation according to recognized guidelines and the score grid was created with the answers of 20 experts. Responses of 644 participants (average age = 36.9 years, SD = 9.0, 348 / 54.03% nursing students and 296 / 45.96% nurses) to TCSHC Brazilian version were analyzed in terms of association between variables, internal consistency index, and confirmatory and exploratory factorial analyses. Results: The 92 items and instructions of the TCSHC were adapted for Brazil. Of the 92 items, 39 were excluded by item-total correlation <0.2. The TCSHC Brazilian version consisted of 53 items, with Cronbach\'s alpha of 0.87. Confirmatory and exploratory factor analyzes did not identify theoretical structure or interpretable structure for the 53 items. The mean TCSHC scores of the specialists, nurses and students were different (F = 12.135; p = 0.000); (p = 0.021) and that the students (p = 0.021) and the nurses had better scores (p = 0.001), evidencing the discriminant validity of the TCSHC Brazilian version. There was an association between clinical reasoning and sex (women with higher scores than men; t = -3.33, p = 0.001); Students exposed to the nursing process had better scores than those not exposed (t = -2.72; p = 0.007); Among the nurses, there was significant association between the highest degree of training and clinical reasoning (F = 4,772, p = 0.003, doctorate> specialization (p = 0.002) and> graduation (p = 0.033). Neither there was correlation between clinical reasoning and time of experience among the nurses (r = 0.158, p = 0.006), nor with the students\' current graduation phase among the students (r = 0.144, p = 0.007) Conclusion: The TCSHC Brazilian version presented evidence of satisfactory reliability with a good measure of discriminant validity. As for the construct validity it was not possible to confirm the proposed structure for the original instrument, nor to identify an interpretable structure.

<p>Uppsatsens syfte var att beskriva hur arbetsterapeuter resonerar kliniskt vid bedömning av arbetsförmåga hos personer med neuropsykiatriska funktionsnedsättningar. För denna studie användes en kvalitativ ansats. Semistrukturerade intervjuer genomfördes med fem arbetsterapeuter som jobbar mot arbetsmarknaden. Frågeområdena inspirerades av <em>clinical reasoning </em>”three track mind” där <em>procedural, interactive</em> och <em>conditional reasoning</em> utgör de tre olika tankemönstren.</p><p>Resultatet redovisades i fyra kategorier och ett övergripande tema som beskriver arbetsterapeuternas kliniska resonemang: Att forma en frågeställning, Att välja bedömningsmetod, Att utforma en slutrapport och Yrkeskompetens. Det övergripande temat, Att se till olika aspekter vid bedömning, visar den röda tråden genom kategorierna. Resultatet i vår studie visar på den komplexitet som finns i de resonemang som förs vid bedömning av arbetsförmåga. Något som kan jämföras med <em>clinical reasonings</em> "three track mind" och som framkommer i vårt tema; <em>Att se till olika aspekter vid bedömning.</em> De deltagande arbetsterapeuterna beskriver hur resonemanget i arbetsförmågebedömningarna sker utifrån en mängd olika aspekter, och arbetsterapeuterna menar att de hela tiden måste se till både delarna och helheten. Vilka svårigheter som finns och hur olika faktorer påverkar personen de bedömer, och hur alla faktorer tillsammans är avgörande för personens arbetsförmåga.</p>

<p>Background: Practice knowledge exists as a complex relationship between questions and answers in a context of meaning that is often intuitive and hidden from the novice practitioner. Physiotherapy education, which aims to develop patterns of thinking, reflection and reasoning as part of practice knowledge, is often based on didactic teaching methods that emphasise the learning of facts without highlighting the relationships between them. In order to improve health outcomes for patients, clinical educators must&nbsp / consider redesigning the curriculum to take into account the changing and complex nature of physiotherapy education. There is some evidence that a blended approach to&nbsp / teaching and learning may facilitate the development of graduates who are more capable of reflection, reasoning and critical thinking, and who can adapt and respond to the&nbsp / complex clinical environment. The purpose of this study was to develop principles that could be used to guide the design of blended learning environments that aim to develop&nbsp / capability in undergraduate physiotherapy students. Method: The study took place in a university physiotherapy department in the Western Cape in South Africa, among&nbsp / undergraduate students. Design research was used as a framework to guide the study, and included a range of research methods as part of that process. The problem was&nbsp / identified using a systematic review of the literature and a survey of students. The design of the blended intervention that aimed to address the problem was informed by a&nbsp / narrative review of theoretical frameworks, two pilot studies that evaluated different aspects of blended learning, and a Delphi study. This process led to the development of a set&nbsp / of design principles which were used to inform the blended intervention, which was implemented and evaluated during 2012. Results: The final results showed that students had undergone a transformation in how they thought about the process and practice of learning as part of physiotherapy education, demonstrating critical approaches towards&nbsp / knowledge, the profession and authority. These changes were brought about by changing teaching and learning practices that were informed by the design principles in the&nbsp / preliminary phases of the project. These principles emphasised the use of technology to interact, articulate understanding, build relationships, embrace complexity, encourage&nbsp / creativity, stimulate reflection, acknowledge emotion, enhance flexibility and immerse students in the learning space. Discussion: While clinical education is a complex undertaking with many challenges, evidence presented in this study demonstrates that the development of clinical reasoning, critical thinking and reflection can be enhanced through the intentional use of technology as part of a blended approach to teaching and learning. The design principles offer clinical educators a framework upon which to construct learning environments where the affordances of technology can be mapped to the principles, which are based on a sound pedagogical foundation. In this way, the use of technology in the learning environment is constructed around principles that are informed by theory. However, clinical educators who are considering the integration of&nbsp / innovative strategies in the curriculum should be aware that students may initially be reluctant to engage in self-directed learning activities, and that resistance from colleagues&nbsp / may obstruct the process. Conclusion: The development of clinical reasoning, critical thinking and reflection in undergraduate physiotherapy students may be enhanced through&nbsp / the intentional use of appropriate technology that aims to fundamentally change teaching and learning practices. Design research offers a practical approach to conducting&nbsp / research in clinical education, leading to the development of principles of learning that are based on theory. <br /> iii</p>

Forming a medical diagnosis is a complicated reasoning process undertaken by physicians. Although there has been much research focusing on clinical reasoning approaches, there is limited empirical evidence in relation to causal attribution in medical diagnosis. The research on which this thesis is based explored and examined the social process of medical diagnosis and provides an explanation of the clinical reasoning and causal attribution used by physicians. The research was undertaken in an Emergency Department within an acute hospital, the data were collected using mixed method approach including one to one semi-structured interviews with individual physicians; observation of their medical assessments of patients and secondary data analysis of the subsequent recorded medical notes. The study involved 202 patients and 26 physicians. The analysis of the physicians’ semi-structured interviews, shows how physicians describe the diagnostic step process and how they blend their clinical reasoning skills and professional judgment with evidence-based medicine. Physicians apply prior learning of taught biomedical and pathophysiological knowledge to question patients using pattern recognition of common signs and symptoms of disease. These findings are portrayed through taped narratives of the physician/patient interaction during the medical diagnostic process, which shows how physicians control the medical encounter. The analysis/interpretation of documentary evidence (recorded medical notes) provides an insight into the way in which physicians used the information gathered during the diagnostic step process. By using SPSS it was possible to cluster the cases (individual patients) into groups. This stage-ordered classification procedure demonstrated commonality amongst individual cases whilst highlighting the uniqueness of any cases. A pattern emerged of two groups of cases: Group 1 - comprised of patients with the presenting complaints of chest pain, shortness of breath, collapse, abdominal pain, per rectal bleed, nausea, vascular and neurological problems and Group 2 - comprised of patients presenting with trauma, mechanical falls, miscarriage/gynaecological problems, allergies/rashes and dental problems. Findings show that the clinical reasoning approaches used varied according to the complexity of the patient’s presenting complaint. The recorded medical notes for the patients in Group 1, were comprehensive and demonstrated a combined approach of hypothetic-deductive and probabilistic reasoning which enabled the physicians to deal with the degree of uncertainty that is inherent in medicine. The recorded process in the medical notes was shortened for the majority of patients in Group 2, and here the clinical reasoning approach used was found to deterministic. It is acknowledged, that this is not always the case. By using crisp set QCA it was possible to explore causal conditions consistent with Group 1. Further analysis led to examination of the link of causal conditions presented in the medical notes with the individual impression/working diagnosis made by physicians.

The British government currently requires mental health services to be targeted at the most needy (Department of Health, 1999). For occupational therapy services, where service demand far exceeds service availability, skill in referral prioritisation is essential. The studies in this thesis describe how experienced occupational therapists’ referral prioritisation policies were used to successfully educate novices. 40 British occupational therapists’ referral prioritisation policies were modelled using judgement analysis. Individuals’ prioritisation decisions were regressed onto 90 referral scenarios to statistically model how referral information had been used. It was found that the reason for referral, history of violence and diagnosis were most important. The occupational therapists’ capacity for self-insight into their policies was also examined by comparing statistically modelled policies derived from their behaviour with their subjective view of their cue use. Self-insight was found to be moderate (mean r = 0.61). A Ward’s cluster analysis was used on the statistically modelled policies to identify if subgroups of therapists had differing referral prioritisation policies. Four clusters were found. They differed according to several factors including the percentage of role dedicated to specialist occupational therapy rather than generic work. The policies that led to more of an occupational therapy role were found to give particular importance to the reason for referral and the client’s diagnosis. The occupational therapy professional body supports this latter method of working as it has recommended that occupational therapists should use their specialist skills to ensure clients’ needs are met effectively. Therefore the policies that focussed on clients’ occupational functioning were used to train the novices. Thirty-seven students were asked to prioritise a set of referrals before and after being shown graphical and descriptive representations of the policies. Students gained statistically significant improvements in prioritisation. Students’ pre-training policies were found to be those of generic therapists; a method of working that has been found to be leading to reduced work satisfaction and burnout (Craik et al.1998b). The training is therefore needed to ensure undergraduate occupational therapy students develop effective referral prioritisation skills. This will help to ensure that clients’ needs are met most effectively and work stress is reduced.

Spirituality is contentious in occupational therapy. Theoretically ill-defined and under-researched by the profession, spirituality is difficult for therapists to address in practice. Relatively few guidelines exist for incorporating spirituality within the enabling process. Accordingly, therapists individually determine their parameters around addressing spirituality in therapy. This has led to some concerns regarding how therapists with a firm religious orientation approach spirituality in practice. This study used in-depth interviews to explore the experiences of seven Christian occupational therapists for whom spirituality was personally important. Their beliefs provided a perspective that influenced clinical reasoning. Christian faith was a unique resource used in practice, distinguishing their work experience from that of their colleagues. To varying degrees, fear of reprimand by the College of Occupational Therapists of Ontario inhibited the extent to which Christian faith was incorporated into therapy. Showing faith rather than sharing faith enabled participants to practice within regulatory guidelines.