This qualitative study describes how physical therapist experts in musculoskeletal disorders evaluate and interpret imaging studies and how they employ imaging in clinical decision-making. The informants are physical therapists who are certified orthopedic clinical specialists (OCS) and/or fellows of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). The study employed web conferencing to display patient cases, record screen-capture videos, and to conduct interviews. Informants were observed and their activity video-captured as they evaluated imaging studies and, afterwards, interviews were employed to explore the processes they utilized to evaluate and interpret the images and to discuss imaging-related clinical decision-making, including possible functional consequences of changes seen in the images, contraindications to treatment, and indications for referral. The interviews were transcribed and analyzed in the tradition of grounded theory. This study found that the informants’ evaluation of imaging studies was contextual and non-systematic, guided by the clinical presentation. The informants used imaging studies to provide a deeper understanding of clinical findings and widen perspectives, arriving at clinical decisions through the synthesis of imaging, clinical findings, and didactic knowledge. They tended to look for imaging evidence of interference with normal motion, rather than evidence of pathology. Overall, the informants expressed conservative views on the use of imaging, noting they would rather use clinical findings and treatment response than imaging findings as a basis for referral to other health care professionals. Using imaging studies to support clinical decision-making can provide physical therapists a wider perspective when planning treatment interventions. By showing physical therapists’ approach to interpreting imaging studies and how this relates to their clinical decision-making, the findings of this study could contribute to discussions of the place of imaging in physical therapist practice, as well as help set objectives for imaging curricula in professional-level and continuing education.

"May 2007" A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Occupational Therapy. Typescript Project Advisor : Max A. Ito Occupational therapy candidates face a challenging task on the path to becoming registered occupational therapists. Uncertainty surrounds the professional community as to why certain candidates, who otherwise perform soundly both academically and clinically, struggle to be successful on the certification exam. Literature suggests that factors such as stress and anxiety may be the root cause. There is a plethora of literature discussing the importance of clinical reasoning skills in occupational therapy practitioners and students. However, no literary sources to date have investigated the importance of clinical reasoning in certification exam performance. This research study investigated the correlation between clinical reasoning skills and performance on the NBCOT certification examination. Thirty-five candidates from across the U.S. completed the Health Sciences Reasoning Test (HSRT), which tests critical thinking skills in five key areas. Supporting demographic information was collected for further comparisons. The participants then sat for the NBCOT exam within 90 days of taking the HSRT. Pearson product-moment correlation and Spearman's rho analyses indicated significant relationships between certification exam performance and three sub-skills of reasoning: inductive reasoning (p = .032/rs = .011), deductive reasoning (p = .007/rs = .004), and analytical reasoning (p = .001/rs = .002). Total HSRT score was also a significant factor in exam performance (p = .001/rs = .003). In ANOVA analysis investigating the relationship between highest educational level and certification exam performance, students who earned only master's degrees in occupational therapy performed significantly better than those earning combined bachelor's/master's degrees (p = .000), scoring an average of 29.15 points higher on the certification exam. In additional analysis, multiple regression analysis indicated that only analytical reasoning was a predictor of certification exam score. Race, age, grade point average (GPA), geographic location, and fieldwork settings were not significant factors in certification exam performance. Application of these results to larger populations should be exercised with caution due to the limited sample size of this study. Results of this study can initiate a dialogue among occupational therapy practitioners and educators who hold a role in assisting students in developing clinical reasoning skills and preparation for the certification exam. Results are also beneficial for students who can incorporate clinical reasoning skills as part of a certification exam study regimen.

Sammanfattning Syftet: Syftet med studien var att beskriva arbetsterapeuters kliniska resonemang vid hemrehabilitering av personer med stroke. Metod: Studien genomfördes med en kvalitativ ansats för att beskriva subjektiva upplevelser. Nio semistrukturerade intervjuer genomfördes med arbetsterapeuter verksamma i hemsjukvården och analyserades utifrån kvalitativ innehållsanalys. Resultat: Analysen resulterade i fem kategorier: Personcentrerat förhållningssätt, Arbetsterapi i samverkan, Miljöns betydelse, Etiskt förhållningssätt och Resurser. Resultatet redovisar att arbetsterapeuterna i studien resonerar kring de kliniska resonemangen men har inte alltid de resurser som krävs för att kunna nyttja hela sin kompetens. Ett huvudfynd i studien var arbetsterapeuternas resonerande och beaktande av personcentrering vid hemrehabilitering. Personcentreringen ansågs vara det centrala fokuset och utgångspunkt för en lyckad rehabilitering. Resultatet visade även att erfarenhet är något som arbetsterapeuterna utvecklar över tid och att resonemanget varierar beroende på den erfarenhet som arbetsterapeuten har. Slutsats: Den slutsats som författarna kom fram till är att arbetsterapeuter behöver få tid för att kunna arbeta personcentrerat och nyttja hela sin kompetens. Studien har bidragit till en ökad förståelse för hur arbetsterapeuter resonerar utifrån det kliniska resonemanget och hur det leder till praktiskt professionsutövande. Författarna ser dock behovet av ytterligare studier för att öka kunskapen om arbetsterapeuters kliniska resonemang. / Abstract  Purpose: The purpose of the study was to describe occupational therapists' clinical reasoning in home rehabilitation of people with stroke. Method: The study was conducted with a qualitative approach to describe subjective experiences. Nine semi-structured interviews were conducted with occupational therapists active in home health care and analyzed based on qualitative content analysis. Results: The analysis resulted in five categories: Person-centred approach, Occupational therapy in collaboration, Importance of the environment, Ethical approach and Resources. The results show that the occupational therapists in the study reason around the clinical reasoning but do not always have the resources required to be able to use their full competence. A main finding in the study was the occupational therapists' reasoning and consideration of person-centredness in home rehabilitation. Person-centredness was considered to be the central focus and starting point for successful rehabilitation. The results also showed that experience is something that occupational therapists develop over time and that the reasoning varies depending on the experience that the occupational therapist has. Conclusion: The conclusion that the authors reached is that occupational therapists need to be given time to be able to work person-centredly and use their full competence. The study has contributed to an increased understanding of how occupational therapists reason based on clinical reasoning and how this leads to practical professional practice. However, the authors see the need for further studies to increase knowledge of occupational therapists' clinical reasoning.

Indiana University-Purdue University Indianapolis (IUPUI) / There is a critical need for faculty, a shortage of clinical sites, and an emphasis on quality and safety initiatives that drive increasing use of simulation in nursing education. Debriefing is an essential component of simulation, yet faculty are not consistently prepared to facilitate it such that meaningful learning, demonstrated through clinical reasoning, occurs from the experience. The purpose of this exploratory, quasi-experimental, pre-test-post-test study was to discover the effect of the use of a simulation teaching strategy, Debriefing for Meaningful Learning (DML), on the development of clinical reasoning in nursing students. Clinical reasoning was measured in 238 participant students from a Midwestern university school of nursing taking an adult health course that uses simulation. Participants were assigned to either the experimental or control group where the DML was compared to customary debriefing using the Health Sciences Reasoning Test (HSRT) before and after the debriefing experience, and the Debriefing Assessment for Simulation in Healthcare©–Student Version (DASH©–SV) with four supplemental questions about the DML (DMLSQ) process, during the post-debriefing assessment. This research sought to understand if the DML debriefing strategy positively influenced the development of clinical reasoning skills in undergraduate nursing students, as compared to usual and customary debriefing. The data revealed that there was a statistical difference between total mean test scores measured by the HSRT. There was, additionally, statistical significance in the change in scores between pre-test and post-test for those who used the DML as compared to the control. There was also a difference in the student’s perception of the quality of the debriefing measured by the DASH©–SV with the DML rated statistically higher than usual debriefing. Finally, there was a significant correlation, demonstrated through regression analysis, between the change in HSRT scores and students’ perception of quality debriefing and the use of the DML. This study contributes to the growing body of knowledge about simulation pedagogy, provides tools for use in debriefing, and informs faculty on best practices in debriefing.

Introduction: Early supported discharge intervention offers strokerehabilitation in the home environment. Digitalisation in society may make it demanding to perform everyday activities in traditional ways. Considering that the use of technology now is part of our daily activities, occupational therapists need to maintain a client-centred practice and make sure that their own competencies in using the technology is adequate. Aim: The aim with this study is to explore occupational therapists' perceptions and experiences of interventions involving digital technology with post-stroke patients in early supported discharge settings. Method: A qualitative study with aphenomenological approach was carried out. Four interviews of occupational therapists were conducted. A qualitative content analysis approach was done for the analysis. Findings: Two main categories emerged which were interpreted into the theme Digitalization requires clinical reasoning. Many factors that involved the digitalization of today's society affected both the patients' occupations pre- and post-stroke and therefore also affected the OTs roles and work process. Conclusions: This study highlights that more knowledge is required regarding digital technology and enhancing competence and clinical reasoning within the occupational therapy practice process. Significance: This3study may provide a better understanding for the potential effects that digitalization has within occupational therapy practise.

There is much debate on the best way to educate students on how to generate hypotheses to enhance clinical reasoning in nursing education. To increase opportunities for nursing programs to promote the discovery of accurate and broad-level hypotheses, scholars recommend abductive reasoning which offers an alternative approach to hypothetico-deductive reasoning. This study explored the effects of abductive reasoning training on hypothesis generation abilities (accuracy, expertise, breadth) of first and second year baccalaureate nursing students in a problem-based learning curriculum. A quasi-experiment with 64 participants (29 control, 35 experimental) was conducted. Based on their allocation, study participants either took part in abductive reasoning training or informal group discussion. Three different test questionnaires, each with a unique care scenario, were used to assess participants’ hypothesis generation abilities at baseline, immediate post-test and one-week follow-up. Content validity for care scenarios and other study materials was obtained from content academic experts. Compared to control participants, experimental participants showed significant improvements at follow-up on hypothesis accuracy (p=0.05), expertise (p=0.006), and breadth (p=0.003). While control participants’ hypotheses displayed a superficial understanding of care situations, experimental participants’ hypotheses reflected increased accuracy, expertise and breadth. This study shows that abductive reasoning, as a scaffolding teaching and learning strategy, can allow nursing students to discover underlying salient patterns in order to better understand and explain the complex realities of care situations. Educating nursing students in abductive reasoning could enable them to adapt existing competencies when trying to accurately and holistically understand newer complex care situations. This could lead to a more holistic, person-based approach to care which will allow nursing students to see various health-related issues as integrated rather than separate. / Thesis / Doctor of Philosophy (PhD) / This study explored the effects of a training program on hypothesis generation abilities of nursing students. The training program aimed to teach students how to think more broadly about care situations. Student’s hypothesis generation abilities were measured through the use of three care scenarios, each of which was presented before, immediately after and one-week after the training program. Only first and second year nursing students were included in the study. About half of the students were provided with the training while the other half were provided with informal discussion about hypothesis generation. After one-week, it was discovered that students who received the training had improved significantly in their ability to generate broad hypotheses. These students also generated hypotheses that were more accurate than the other group of students who did not receive the training. Due to the training, students’ abilities in discovering the important aspects of the care situation also improved.

The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) describes Orthopedic Manual Therapy (OMT) as a specialist field in physiotherapy for the treatment of neuromusculoskeletal conditions based on clinical reasoning. The aim of this study was to explore how students in a OMT physiotherapy master programme describe their clinical reasoning. Nine participants were included in the study. Data was collected using a semi-structured interview guide and were analyzed with qualitative content analysis. The analysis resulted in one main category: “A multidimensional picture of clinical reasoning” and three categories: 1) Confidence in the role as physiotherapist; 2) Decision making, a cognitive analytical process 3) Creating alliance and involving the patient in the clinical reasoning. The participants described a multidimensional picture of clinical reasoning which gradually developed and eventually encompassed several aspects in the subcategories. The conclusion of the study is that all the parts above are needed in the clinical reasoning and it takes years to develop effective clinical reasoning. For future studies, it would be of interest to explore how recently graduated physiotherapists with a bachelor degree describe their clinical reasoning.

Résumé: INTRODUCTION Si les cliniciens enseignants détectent aisément les difficultés des apprenants, ils sont souvent peu outillés pour les étapes subséquentes, du diagnostic à la remédiation. Quoique des outils aient été développés pour les guider face aux difficultés de raisonnement clinique de leurs apprenants, ces outils peuvent être moins familiers des cliniciens et moins adaptés à des contextes de supervision ponctuelle et de soins aigus comme l’urgence. Nous avons donc développé une application algorithmique, à partir de la taxonomie d’Audétat et al. (2010), pour guider les cliniciens enseignants juste-à-temps face aux difficultés de raisonnement clinique. MÉTHODOLOGIE Une étude descriptive interprétative a été réalisée afin d’évaluer l’utilité, l’acceptabilité et la faisabilité d’utiliser cette application à l’urgence. Des entrevues semi-dirigées ont été menées auprès d’un échantillon de convenance de douze urgentistes, avant et après une période d’essai de l’outil de trois mois. RÉSULTATS L’application a été perçue comme particulièrement utile pour préciser les difficultés de raisonnement clinique des apprenants. Utiliser l’outil a été considérée acceptable et faisable en contexte d’urgence, en particulier grâce au format mobile. DISCUSSION Ces résultats suggèrent que l’outil peut être considéré utile pour faciliter l’identification des difficultés des apprenants, mais aussi pour offrir un soutien professoral accessible. Le format mobile et algorithmique semble avoir été un facteur facilitant, ce format étant déjà utilisé par les cliniciens pour consulter ponctuellement de l’information lors de la résolution de problèmes cliniques. CONCLUSION L’étude a démontré globalement une bonne utilité, acceptabilité et faisabilité de l’outil dans un contexte de supervision ponctuelle en soins aigus, ce qui soutient son utilisation par les cliniciens enseignants dans ce contexte. L’étude corrobore également l’intérêt d’un format mobile et algorithmique pour favoriser le transfert de connaissances en pédagogie médicale. / Abstract: INTRODUCTION While clinical teachers generally identify problem learners readily, they often find themselves ill-equipped for the following steps, from diagnosis to remediation. Although various tools have been developed to guide them when dealing with problem learners whose difficulties are based in their clinical reasoning, theses tools might be less familiar for clinicians and less well adapted for certain supervision contexts, like the emergency ward, which is characterized by occasional supervision and acute care. Thus we have developed an algorithmic mobile application, based on Audetat et al.’s taxonomy (2010), in order to guide clinicians just-in-time when supervising learners with clinical reasoning difficulties. METHODOLOGY We conducted an interpretive description study with the aim of evaluating the perceived utility, acceptability and feasibility of using this application in the emergency. Semi-structured interviews took place before and after a three-month trial with the tool, with twelve emergency physicians recruited through voluntary sampling. RESULTS The application was considered to be particularly useful to better identify learners’ clinical reasoning difficulties. Consulting this tool in an emergency context was deemed acceptable and feasible by participants, largely due to the mobile format. DISCUSSION These findings suggest that the tool may be considered useful to better identify learners’ difficulties, but also as an accessible reference for clinical teachers. The mobile and algorithmic format seemed instrumental promoting its use, since such formats are already used frequently by clinicians to access information when solving clinical problems. CONCLUSION This study has shown promising results in terms of utility, acceptability and feasibility in a context of occasional supervision and acute care, which support use of the application by clinical teachers in such contexts. This study also suggests that mobile and algorithmic formats may be of value for knowledge transfer in medical education.

Bakgrund: Väl undersökta psykometriska egenskaper krävs för att använda ett instrument. Instrumentet Reasoning 4 Change (R4C) begreppsvaliditet behöver stärkas. Den kan undersökas genom att jämföra det kliniska resonemanget hos extrema grupper vilka kan vara fysioterapeutstudenter med beteendemedicinsk inriktning i olika skeden av utbildningen. Utifrån den social kognitiva teorin kan fysioterapeutstudenterna ses som en viktig omgivningsfaktor för att hjälpa patienter utföra en beteendeförändring. Syfte: Att utvärdera begreppsvalididet för bedömningsinstrumentet R4C genom att jämföra det kliniska resonemanget med fokus på patienters aktivitetsrelaterade beteende och beteendeförändring hos fysioterapeutsstudenter i termin ett och termin sex mätt med instrumentet. Metod: En beskrivande och jämförande tvärsnittsstudie som utgår från data insamlad ifrån flera tillfällen. Totalt deltog 89 termin ett studenter och 47 termin sex studenter. Parametriskt oberoende t-test användes för att analysera resultatet. Resultat: Termin sex studenterna hade signifikant högre resultat på sju av åtta variabler mätt med R4C jämfört med termin ett studenterna, vilket innebar att hypotesen nästan fullständigt bekräftades. Slutsats: Begreppsvaliditeten kan anses som god för den undersökta populationen. För att generalisering till alla fysioterapeutstudenter ska kunna ske behövs vidare forskning. / Background: Evaluation of psychometric properties are necessary to use an instrument. The Reasoning 4 Change (R4C) instrument’s construct validity needs to be strengthened. It can be done by comparing the clinical reasoning by extreme groups which can be physiotherapy students with a behavioral approach in different stages of the education. From the social cognitive theory's perspective, the students can be an important environmental factor to help clients’ perform a behavioral-change. Aim: To evaluate construct validity for the R4C instrument by comparing the clinical reasoning with focus on clients’ activity-related behaviour and behaviour change by physiotherapy students in the first and sixth semester measured with the instrument. Method: A describing and comparing cross-sectional study with data collected from several occasions. A total of 89 first semester students and 47 sixth semester students participated in the study. Parametric independent t-test was used to analyse the results. Result: Students in the sixth semester had significant higher results on seven out of eight variables measured with R4C compared with students in the first semester, that indicate that the hypothesis almost is confirmed. Conclusion: The construct validity can be considered good for the evaluated population. To be able to generalize to all physiotherapy students more studies would be necessary.

La récente réingénierie des études de soignants paramédicaux en général et celle de MK en particulier (en 2015), introduit une nouvelle dimension dans les cycles de formation : le raisonnement clinique. Défini par Higgs (2008) comme « processus de pensée et de prise de décision qui permet au clinicien de prendre les actions les plus appropriées dans un contexte spécifique de résolutions de problèmes de santé », celui-ci vise à développer et évaluer chez les apprenants leur capacité à lier des savoirs concernant la situation de la personne malade (bio-psycho et social) et des savoirs professionnels, techniques, cognitifs et relationnels. En s’intéressant au processus d’institutionnalisation du raisonnement clinique, cette thèse interroge les processus d’enseignement (notamment des tuteurs de stage) et d’apprentissage de cette pratique par les futurs MK, notamment à partir des différentes séquences proposées. Le raisonnement clinique fait appel à une pluralité de schèmes au sens de Pastré (2011) mobilisés par les apprenants pour analyser un problème de santé et construire un projet de soin pour la personne malade. La compréhension de la mobilisation de tous ces schèmes, le modus operandi des étudiants en situation d’apprentissage du raisonnement clinique occupe une place centrale dans cette thèse inscrite clairement dans une didactique professionnelle. Réalisée à partir d’observations de terrain, de séances d’apprentissage filmées, d’entretiens et d’hétéroconfrontations (N=20) auprès de patients, tuteurs libéraux et étudiants stagiaires, cette recherche a permis de catégoriser par une méthode qualitative d’analyse de contenu, à l’aide du logiciel N’Vivo, les 5 portraits des triades patient/tuteur/étudiant en s’appuyant, entre autres, sur les ressources mobilisées (Piot, 2009) et les configurations de tutorat (Kunegel, 2011). Nous tentons ensuite de repérer des grandes lignes de force ou de divergence entre les différents portraits. Le raisonnement en kinésithérapie serait un outil favorable à l’incorporation de savoirs théoriques abstraits mobilisés en situation pratique avec les patients, qui sont adaptés et incorporées par chacun. Il est un outil de bricoleur, un fil rouge qui permet l’adaptation au patient et dont les tuteurs cherchent à s’émanciper pour leur pratique de « la vraie vie », dans un style qui leur est propre, au sein du genre kinésithérapique. La première séance serait un moment d’étonnement voire d’éblouissement pour l’étudiant. Le patient est un tiers totalement intégré dans le processus de la séance, qui par sa fonction de médiation, aide à l’intégration des savoirs et à l’apprentissage du raisonnement clinique. Nous proposons une modélisation de celui-ci en co médiation. / The recent re-engineering of paramedic studies in general and of MK in particular (En 2015) introduces a new dimension in the training cycles: the clinical Rai-ringing. Defined by Higgs (2008) as "a process of thought and decision-making that allows the clinician to take the most appropriate actions in a specific context of health problem solving", the beneficial aims to develop and evaluate among AP-stakeholders their ability to link knowledge about the situation of the sick person (bio-psycho and social) and professional, technical, cognitive and relational knowledge. By focusing on the process of institutionalizing clinical reasoning, this inter-Roge thesis processes teaching (especially tutors of internship) and learning this practice by the future MK, especially from the different proposed sequences. Clinical reasoning uses a plurality of patterns in the sense of Pastré (2011) Mobili-Con by learners to analyze a health problem and build a care project for the sick person. The understanding of the mobilization of all these patterns, the modus-Randi of students in learning situation of clinical reasoning occupies a central place in this thesis clearly enshrined in a professional didactics. Based on field observations, filmed learning sessions, interviews and hétéroconfrontations (N = 20) with patients, liberal tutors and student interns, this research has allowed to categorize by a qualitative method Content analysis, using the No Vivo software, the 5 portraits of the patient/tutor/student triad based, among other things, on the resources mobilized (2009) and the tutoring configurations (Kunegel, 2011). We can then try to identify the main lines of force or divergence between the different portraits. The reasoning in physiotherapy would be a favourable tool for incorporating abstract theoretical knowledge mobilized in practical situations with patients, which are adapted and incorporated by each. It is a handyman's tool, a red thread that allows adaptation to the patient and whose tutor seeks to emancipate himself or herselffor the practice of "real life", in a style of his own, within the genus Kinésithérapique. The first session would be a moment of astonishment or even amazement for the student. The patient is a third party totally integrated into the process of the session, which through its function of mediation, helps the integration of knowledge and the learning of clinical reasoning. We propose a modeling of it in co- mediation.