<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>

Background: Cognitive processing in diagnostic oral radiology requires a solid foundation in the basic sciences as well as knowledge of the radiologic changes associated with disease. Although it is generally assumed that in dentistry, students must acquire both knowledge sets, little is known about the role or impact of the basic sciences on clinical reasoning because the two have traditionally been taught separately in the curriculum. Objectives: This dissertation investigates the role of basic sciences in oral radiology and its effects on diagnostic accuracy. The studies were designed to satisfy the following research aims: 1) to examine and compare the effects of integration and segregation of the basic and clinical sciences on diagnostic accuracy; 2) to examine the effects of basic science instructional methodology and diagnostic strategy on diagnostic outcomes; 3) to explore the potential interactions between instructional methodologies used to teach disease categorization and diagnostic strategies; and 4) to examine the effects of testing the basic sciences on diagnostic accuracy in an integrated instructional methodology. Methods: We conducted three quantitative studies, all of which involved a learning phase and an immediate testing phase that assessed diagnostic performance and memory. In each of the studies, learning strategies, and or testing frequency were varied. We also included performance assessment of diagnostic ability and memory, one week after the initial learning phase. Results: Our results show that students who learned basic sciences explanations had higher diagnostic accuracy when using a holistic System 1 type diagnostic strategy than those who did not. We also demonstrated that basic science knowledge was the most effective when directly integrated with the clinical sciences, and this result is further enhanced with testing. Conclusions: We conclude that integrated basic science learning provides a coherent framework that has the potential to significantly improve the diagnostic accuracy of training dentists.

Background: Cognitive processing in diagnostic oral radiology requires a solid foundation in the basic sciences as well as knowledge of the radiologic changes associated with disease. Although it is generally assumed that in dentistry, students must acquire both knowledge sets, little is known about the role or impact of the basic sciences on clinical reasoning because the two have traditionally been taught separately in the curriculum. Objectives: This dissertation investigates the role of basic sciences in oral radiology and its effects on diagnostic accuracy. The studies were designed to satisfy the following research aims: 1) to examine and compare the effects of integration and segregation of the basic and clinical sciences on diagnostic accuracy; 2) to examine the effects of basic science instructional methodology and diagnostic strategy on diagnostic outcomes; 3) to explore the potential interactions between instructional methodologies used to teach disease categorization and diagnostic strategies; and 4) to examine the effects of testing the basic sciences on diagnostic accuracy in an integrated instructional methodology. Methods: We conducted three quantitative studies, all of which involved a learning phase and an immediate testing phase that assessed diagnostic performance and memory. In each of the studies, learning strategies, and or testing frequency were varied. We also included performance assessment of diagnostic ability and memory, one week after the initial learning phase. Results: Our results show that students who learned basic sciences explanations had higher diagnostic accuracy when using a holistic System 1 type diagnostic strategy than those who did not. We also demonstrated that basic science knowledge was the most effective when directly integrated with the clinical sciences, and this result is further enhanced with testing. Conclusions: We conclude that integrated basic science learning provides a coherent framework that has the potential to significantly improve the diagnostic accuracy of training dentists.

Introduction: Clinical reasoning plays a crucial role in the provision of quality medical care. The consequences of poor clinical reasoning affect not only the patient concerned but the cost and effectiveness of the entire health care system. The aims of this thesis are three-fold: to monitor the development of clinical reasoning in students enrolled in a graduate-entry, problem-based learning program in a large medical school; to compare the clinical reasoning of these students at graduation with that of graduates of a traditional undergraduate course; and to gain insight into the nature of the clinical reasoning process which may be applicable to the teaching and evaluation of medical curricula. Methods: Two methods have been used to assess clinical reasoning. The first method, the Clinical Reasoning Problems (CRPs), was developed to meet specific criteria established for this study. A CRP is a short clinical scenario that provides information about a patient’s presentation, history and physical examination. It is designed to assess the first three steps in the clinical reasoning process – identification and interpretation of pertinent data, and hypothesis generation. Subjects are required to nominate the two most likely diagnoses and to identify and interpret the clinical features that they considered in arriving at each diagnosis. Responses are marked using a scoring system based on, and derived from, those of a reference group of experienced general practitioners (GPs). The CRPs are presented as a set of ten problems, each taking about ten minutes to complete. The second method used was the Diagnostic Thinking Inventory (DTI). This is a questionnaire designed to probe clinical reasoning style by assessing two aspects of clinical reasoning: flexibility of thinking and the degree of structure of knowledge in memory. In this way, and because it is not tied to a specific clinical scenario, it provides an assessment of reasoning style that is independent of the content of a subject’s knowledge base. Subjects: Subjects were volunteer medical students from the last cohort of the undergraduate course and the first three cohorts of the new, graduate-entry MBBS Program at the University of Queensland. The reference group consisted of twenty-two GPs voluntarily recruited from all areas of Queensland. Results: Evaluation of the CRPs showed them to be a reliable and valid method for the assessment of clinical reasoning skill over a range of competence levels. The reliability of the DTI was similar to that found in other studies. Analysis of data collected using these methods showed that scores on both the CRPs and the DTI increased significantly in all student cohorts throughout the MBBS Program. Factors which influence performance on one or other of these indicators include stage of progression through the MBBS, gender, academic background and pre-admission interview score. Analysis of the causes of poor performance on the CRPs strongly suggests that medical students in the latter part of the MBBS have reached an intermediate stage in the development of reasoning expertise. This stage is characterised by the possession of a large but poorly structured body of knowledge. Subsequent examination of the CRP responses of the 21 reference GPs led to the classification of six of the GPs as diagnostic experts on the basis of their response patterns. Comparison of these GPs with the remaining 15 in the reference group has provided valuable information about the clinical reasoning characteristics of diagnostic experts and the relationship of the clinical reasoning process to diagnostic expertise. The principal finding was that integration of clinical data - the ability to connect relevant, accurately interpreted clinical information in such a way as to lead to the correct diagnosis - is the most critical step in the clinical reasoning process. This step is commonly disregarded or under-emphasised in the literature. Conclusion: This thesis indicates that both the style, and level of skill, of clinical reasoning develops significantly in MBBS students throughout their undergraduate medical education. In addition, it has demonstrated that the ability to integrate clinical information is a distinguishing characteristic of the clinical reasoning process of diagnostic experts. Although it is accepted that further development into true expertise can only occur as a result of extensive independent clinical experience, these findings are highly relevant to both the teaching and evaluation of medical curricula.

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.

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 clinical reasoning ”three track mind” där procedural, interactive och conditional reasoning utgör de tre olika tankemönstren. 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 clinical reasonings "three track mind" och som framkommer i vårt tema; Att se till olika aspekter vid bedömning. 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.

Background: Clinical reasoning is the ability to reason as a clinical situation changes and is an essential component of competence in nursing practice. However, some traditional teaching and learning strategies do not always facilitate the development of the desired clinical reasoning skills in nursing students. Problem statement: Nurse educators at a military nursing college in Gauteng are predominantly utilising traditional teacher-centred teaching and learning strategies. The concern is that if students are predominantly taught by means of traditional teacher-centred strategies this may not contribute to the development of the desired clinical reasoning skills required for nursing practice. To improve educational practices to promote the development of student nurses' clinical reasoning skills, the researcher conducted an action research study. Aim: The aim of the study was to facilitate a process of change towards improving educational practices in order to promote the development of undergraduate student nurses' clinical reasoning skills. Methodology: Action research was used to conduct the research study by means of three phases. During Phase 1: the Baseline phase, data was collected by means of unstructured interviews with nurse educators and head of departments to explore and describe the challenges experienced by nurse educators in utilising alternative educational practices. During Phase 2: the Action Research Process phase, an action research group was established to co-construct an action plan to address the identified challenges. Four action research cycles each comprising four steps, namely plan, act, observe and reflect was implemented. Phase 3, the Evaluation of the Action Research Process phase, evaluated the outcomes of the action research process by means of the World Café data collection method. Qualitative data from Phase 2 was analysed using the steps outlined in Saldaña (2013). The activities conducted during the action research group workshops were recorded and minutes were kept. Data from the World Café was analysed using the creative hermeneutic data analysis method as suggested by Boomer and McCormack (2010). Findings: The challenges encountered by nurse educators were explored and the following four main themes emerged: educational practices; clinical learning environment; military learning environment; and role players in the teaching and learning environment. The challenges were prioritised by the action research group into four strategies: teaching, learning and assessment strategies; the clinical learning environment; continuous professional development; and support and selection of students and nurse educators. An action plan was co-constructed during Phase 2 by the action research group participants. The project was evaluated by the action research group as successful. The action research process contributed to the professional development of the nurse educators and resulted in the utilisation of more student-centred teaching, learning and assessment strategies. Conclusions: An action plan was developed to improve educational practices at the South African Military Health Service Nursing College. The researcher also developed a conceptual framework to promote clinical reasoning skills. Addressing nurse educator challenges in collaboration and empowering them with the means, opportunity and skill to utilise studentcentred teaching and learning strategies may contribute to the development of undergraduate student nurses' clinical reasoning skills. / Thesis (PhD)--University of Pretoria, 2017. / Nursing Science / PhD / Unrestricted

Philosophiae Doctor - PhD / 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 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 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 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 capability in undergraduate physiotherapy students. Method: The study took place in a university physiotherapy department in the Western Cape in South Africa, among 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 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 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 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 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 preliminary phases of the project. These principles emphasised the use of technology to interact, articulate understanding, build relationships, embrace complexity, encourage 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 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 may obstruct the process. Conclusion: The development of clinical reasoning, critical thinking and reflection in undergraduate physiotherapy students may be enhanced through the intentional use of appropriate technology that aims to fundamentally change teaching and learning practices. Design research offers a practical approach to conducting research in clinical education, leading to the development of principles of learning that are based on theory. / South Africa

Aim. This investigation aimed to discover if a there is a correlation between a student’s clinical reasoning self-efficacy and a student’s actual clinical reasoning ability. Also, this research sought to discover the connection between an undergraduate nurse’s self-efficacy of clinical reasoning and the locus of control of that student. Finally, this investigation sought to discover if perceived self-efficacy of clinical reasoning changed over time. Background. The ability to successfully navigate the process of clinical reasoning is critical to providing safe, effective care for patients. For nurses, this process begins to develop in nursing school. Unfortunately, evidence suggests that newly graduated nurses struggle to navigate this process successfully, placing patients’ safety in jeopardy. While much research has been dedicated to a student’s clinical reasoning development, little is understood about the variables that impact clinical reasoning development in the student population. Method. Partial correlation was utilized to discover the connection between students’ perceived self-efficacy of clinical reasoning and the students’ actual clinical reasoning ability. Also, a one-way ANOVA, to assess changes over time and reliability assessment of the Nurses’ Clinical Reasoning Scale, was completed. Results. Fifty-two undergraduate nursing students from across 35 states in the United States were included in the sample for this study. Neither a significant relationship between the students’ self-efficacy of clinical reasoning and the students’ actual clinical reasoning ability, nor a significant change over time in perceived self-efficacy scores was detected. Conclusion. By understanding the impact certain factors have on the formation of clinical reasoning ability in students, educators are better equipped to identify those students that might struggle to develop clinical reasoning and intervene in the early stages of development. Additional studies need to be initiated to completely understand the influence these variables have on the development of clinical reasoning.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Clinical reasoning is the central aim of student health professionals’ education. However, educators still find it challenging to teach, and students still struggle to demonstrate clinical reasoning abilities. Various teaching strategies are used by educators to facilitate the development of clinical reasoning abilities, but it is unclear whether educators utilise robust theories to underpin their teaching strategies. Theories can assist with the conceptualisation, simplification and improvement of information. The aim of this study was to explore the use of theory to inform the teaching strategies which develop clinical reasoning in undergraduate health professional students.