Professional Documents
Culture Documents
V
ision 2020, as set forth by the practice, CDM models, clinical rea- 3. Develop a guide or process for
American Physical Therapy soning approaches, and a model of clinical mentoring of clinicians at
Association (APTA), highlights disablement and functioning. The all levels.
the following elements: autonomous physical therapy profession has used
physical therapist practice, direct a variety of conceptual frameworks, 4. Integrate the ICF framework into
access, the doctor of physical ther- most recently the APTA’s Guide to the CDM process using the Guide
apy degree and lifelong education, Physical Therapist Practice3 and to Physical Therapist Practice as
evidence-based practice, practitio- the International Classification of a structural base.
ner of choice, and professionalism.1 Functioning, Disability and Health
As the physical therapy profession (ICF) as set forth by the World Target Setting
strives to reach these goals, more Health Organization.4 This tool was developed for use in a
emphasis is being placed on the pro- large academic hospital network
gram, a literature search was per- lighted the interplay between knowl- conceptual models and case exam-
formed and important concepts edge and reasoning.9 ples that utilize the ICF as a basis for
were realized regarding the topics of decision making.13–17 Recently,
clinical reasoning, models of CDM in In 2003, APTA put forth the Guide to Escorpizo and colleagues12 sug-
physical therapy, reflection, mentor- Physical Therapist Practice (2nd edi- gested a method to integrate the ICF
ship, and expert physical therapist tion), which offers the patient man- into clinical practice documentation.
practice. A common element that agement model as a conceptual As the profession and the Guide to
continually arose was that although framework for clinical decision mak- Physical Therapist Practice evolve
structure or a concrete approach is ing and includes all elements of phys- and seek new ways to integrate the
regarded as very important in both ical therapist practice, including ICF, it becomes important for the
the clinical reflection and mentoring examination, evaluation, interven- clinician to have a practical tool that
process, little exists in the profes- tion, and outcomes.3 This model pro- uses both the ICF and the Guide to
thought process is involved in select- reasoning skills to effectively improved quality of care. Further-
ing specific tests and measures for appraise and integrate evidence into more, it may not be necessarily years
balance assessment. They described practice is essentially linked to of experience that lead to clinician
3 stages of clinical reasoning: (1) ini- Vision 2020. becoming an expert, but rather it is
tial impressions and movement the development of advanced CDM
observation, (2) data gathering, and Outcomes that leads to the expertise associated
(3) diagnosis and treatment plan- A key component of the clinical rea- with improved patient outcomes and
ning. Interestingly, the therapists soning process in generating suc- quality of life.23
involved in their study frequently cessful outcomes is collaboration
looked ahead to their possible diag- with the patient.9,22 Resnik and Reflection
noses and treatment plans when Hart23 ascertained that physical ther- Clinical reflection is a powerful tool
selecting tests and measures during apy expertise is not based on years in developing clinical reasoning
clinical reasoning is the use of struc- nificantly advance their preparation clinical reflection guide to probe rea-
ture.5 Although structured reflective to provide patient care in a defined soning throughout the various stages
learning experiences are common in area of practice.34 Planned postpro- of physical therapist practice. Fur-
physical therapy clinical education fessional clinical education programs thermore, although training work-
for students, little is known about such as these may more quickly shops are available to educate clini-
their use in the common workplace develop an advanced practitioner cians in the art of mentorship, little
for practicing clinicians. Wainwright and can potentially accelerate the specific direction is available to
and colleagues6 studied differences process of developing from a novice help mentors generate questions for
in how novice and experienced cli- to a master clinician.33,35 Structured protégés regarding patient case
nicians use reflection in the CDM reflection and mentorship are funda- examples.
process. They observed that mental to the success of these pro-
although novice clinicians are more grams and ultimately support the Physical Therapy Clinical
lized the evaluation section of the (delayed cognitive processing) to treatment plan and advance the
PT-CRT for a 17-year-old boy with help the patient achieve his goals as patient toward his goals. Finally, the
leukemia and methotrexate toxicity. quickly as possible. When designing emphasis on outcomes and measure-
By using the structure provided by the intervention plan (Fig. 2), the ment guided the resident in selecting
the tool and identifying patient prob- resident initially was overwhelmed appropriate outcome measures that
lems within the context of the ICF, by the multitude of procedural inter- evaluated progress across all
the resident was able to reflect on ventions she wanted to implement domains of the ICF, allowing her to
the factors that were most important with this complex patient. However, evaluate the value of the interven-
to the patient, formulate a plan of by using the reflective questions in tions from a holistic and patient-
care, and identify other resources the intervention section of the centered perspective.
(ie, psychology, social work) to help PT-CRT and having a dialogue with
manage some of the factors outside her mentor, the resident was able to After pilot testing the PT-CRT in our
of the typical scope of physical ther- focus on and prioritize an evidence- residency program, the instrument
apy. The resident also was able to based intervention approach rooted was further trial tested with staff
identify environmental factors that in motor learning strategies such as members as part of the department’s
could be a facilitator or barrier to the task-specific training. The resident professional development program.
patient’s overall progress. By doing used the primary problem areas iden- Mentors received training through a
this, she accentuated the facilitators tified using the ICF and interaction workshop led by experienced clini-
(high motivation) and the barriers with the patient to individualize the cians and other mentors who dis-
VI. Interventions
Figure 2.
Illustration of how the intervention section of the Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) was utilized for
a 17-year-old boy with leukemia and methotrexate toxicity. ICF⫽International Classification of Functioning, Disability and Health.
cussed general concepts of mentor- Outcome her mentor and the tool; this
ship, created role play opportunities, Although the PT-CRT is still in the advancement in skills was confirmed
and introduced the PT-CRT as a early stages of implementation, there by the residency committee during
mechanism to guide mentoring ses- are some promising outcomes to her last practical live patient exami-
sions. Both mentors and protégés report. The PT-CRT catalyzed our nation. She submitted a case study at
welcomed the concept of a work- first department resident to present a the 2011 APTA Combined Sections
sheet to facilitate clinical reasoning case study at the 2010 APTA Com- Meeting using the examples
and have reported success in using bined Sections Meeting and to pub- described in Figures 1 and 2.
the PT-CRT for mentoring discus- lish a Clinical Bottom Line.38,39 Our
sions as well as their own clinical second resident expressed a signifi- The PT-CRT has received positive
reflection. cant shift in CDM and credited both feedback from the rest of staff,
including mentors, protégés, and ultimately, improve outcomes for 5 Shepard KF, Jensen GM. Techniques for
teaching and evaluating students in aca-
department leadership. No negative the patients and clients they serve. demic settings. In: Shepard KF, Jensen
consequences or potential threats GM, eds. Handbook of Teaching for Phys-
ical Therapists. 2nd ed. Boston, MA: But-
have been identified. Different Although the initial data in this case terworth-Heinemann; 2002:71–132.
aspects of the tool seem to be impor- report are promising, more research 6 Wainwright SF, Shepard KF, Harman LB,
tant based on therapist experience is warranted. Collaboration among Stephens J. Novice and experienced phys-
ical therapist clinicians: a comparison of
and comfort with the patient case. residency and fellowship training how reflection is used to inform the clin-
For example, the hypothesis compo- sites to implement the PT-CRT and ical decision-making process. Phys Ther.
2010;90:75– 88.
nents of sections I and II helped to document outcomes through qualita-
7 Lee JE, Ryan-Wenger N. The “Think
advance reflection in a novice clini- tive methods could provide further Aloud” seminar for teaching clinical rea-
cian by prompting anticipation of information about the helpfulness of soning: a case study of a child with phar-
yngitis. J Pediatr Health Care. 1997;11:
the patient’s problems, and then the tool and the clinical reasoning
20 Eva KW. What every teacher needs to 27 Schön DA. The Reflective Practitioner. 35 Hartley G. Postgraduate residency training
know about clinical reasoning [erratum in: New York, NY: Basic Books; 1983. for physical therapists: its role in contem-
Med Educ. 2005;39:753]. Med Educ. 2005; porary practice. HPA Resource. 2006;6:
28 Borleffs JC, Custers EJ, van Gijn J, ten Cate
39:98 –106. 1– 4.
OT. “Clinical reasoning theater”: a new
21 McGinnis PQ, Hack LM, Nixon-Cave K, approach to clinical reasoning education. 36 Block LM, Claffey C, Korow MK, McCaf-
Michlovitz SL. Factors that influence clini- Acad Med. 2003;78:322–325. frey R. The value of mentorship within
cal decision making of physical therapists nursing organizations. Nurs Forum. 2005;
29 Murphy JI. Using focused reflection and
in choosing a balance assessment 40:134 –140.
articulation to promote clinical reasoning:
approach. Phys Ther. 2009;89:233–247. an evidence-based teaching strategy. Nurs 37 Rothstein JM, Echternach JL, Riddle DL.
22 Resnik L, Jensen GM. Using clinical out- Educ Perspect. 2004;25;226 –231. The Hypothesis-oriented algorithm for cli-
comes to explore the theory of expert nicians II (HOAC II): a guide for patient
30 Ali PA, Panther W. Professional develop-
practice in physical therapy. Phys Ther. management. Phys Ther. 2003;83:455–470.
ment and the role of mentorship. Nurs
2003;83:1090 –1106. Stand. 2008;22:35–39. 38 Hanson H, Atkinson H. Rehabilitation of a
23 Resnik L, Hart DL. Using clinical outcomes 13-year old female with an incomplete spi-
31 Schrubbe KF. Mentorship: a critical com-
to identify expert physical therapists. Phys nal cord injury due to Pott’s disease:
ponent for professional growth and aca-
Ther. 2003;83:990 –1002. abstracts of poster presentations at the
Appendix.
The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT)a
REFLECTION POINTS:
➢ Assess how the patient’s medical diagnosis affects your interview.
➢ How might your personal biases/assumptions affect your interview?
a. Body structures/functions
b. Impairments
c. Activity limitations
d. Participation restrictions
REFLECTION POINTS:
➢ Can you construct a hypothesis based on the information gathered?
➢ What is that based on (biases, experiences)?
➢ How did you arrive at the hypothesis? How can you explain your rationale?
➢ What about this patient and the information you have gathered might support your hypothesis?
➢ What do you anticipate could be an outcome for this patient (prognosis)?
➢ Based on your hypothesis, how might your strategy for the examination be influenced?
➢ What is your approach/planned sequence/strategy for the examination?
➢ How might the environmental factors affect your examination?
➢ How might other diagnostic information affect your examination?
(Continued)
Appendix.
Continued
III. Examination
a. Tests and Measures
RELECTION POINTS:
➢ Appraising the tests and measures you selected for your examination, how and why did you select
them?
(Continued)
Appendix.
Continued
IV. Evaluation
HEALTH CONDITION
ENVIRONMENTAL
Internal External
ⴙ ⴚ ⴙ ⴚ
(Continued)
Appendix.
Continued
b. Prognosis
REFLECTION POINTS:
➢ How did you determine your diagnosis? What about this patient suggested your diagnosis?
V. Plan of Care
a. Identify short-term and long-term goals
REFLECTION POINTS:
➢ How have you incorporated the patient’s and family’s goals?
➢ How do the goals reflect your examination and evaluation (ICF framework)?
➢ How did you determine the PT prescription or plan of care (frequency, intensity, anticipated length of
service)?
➢ How do key elements of the PT plan of care relate back to primary diagnosis?
➢ How do the patient’s personal and environmental factors affect the PT plan of care?
(Continued)
Appendix.
Continued
VI. Interventions
a. Describe how you are using evidence to guide your practice
REFLECTION POINTS:
➢ Discuss your overall PT approach or strategies (eg, motor learning, strengthening).
y How will you modify principles for this patient?
y Are there specific aspects about this particular patient to keep in mind?
y How does your approach relate to theory and current evidence?
➢ As you designed your intervention plan, how did you select specific strategies?
➢ What is your rationale for those intervention strategies?
➢ How do the interventions relate to the primary problem areas identified using the ICF?
➢ How might you need to modify your interventions for this particular patient and caregiver? What are
your criteria for doing so?
➢ What are the coordination of care aspects?
➢ What are the communication needs with other team members?
➢ What are the documentation aspects?
➢ How will you ensure safety?
➢ Patient/caregiver education:
y What are your overall strategies for teaching?
y Describe learning styles/barriers and any possible accommodations for the patient and caregiver.
y How can you ensure understanding and buy-in?
y What communication strategies (verbal and nonverbal) will be most successful?
(Continued)
Appendix.
Continued
VII. Reexamination
a. When and how often
REFLECTION POINTS:
➢ Evaluate the effectiveness of your interventions. Do you need to modify anything?
➢ What have you learned about the patient/caregiver that you did not know before?
➢ Using the ICF, how does this patient’s progress toward goals compare with that of other patients with a
VIII. Outcomes
a. Discharge plan (include follow-up, equipment, school/work/community re-entry, etc)
REFLECTION POINTS:
➢ Was PT effective, and what outcome measures did you use to assess the outcome? Was there a
minimum clinically important difference?
➢ Why or why not?
➢ What criteria did you or will you use to determine whether the patient has met his or her goals?
➢ How do you determine the patient is ready to return to home/community/work/school/sports?
➢ What barriers (physical, personal, environmental), if any, are there to discharge?
➢ What are the anticipated life-span needs, and what are they based on?
➢ What might the role of PT be in the future?
➢ What are the patient’s/caregiver’s views of future PT needs?
➢ How can you and the patient/caregiver partner together for a lifetime plan for wellness?
a
PT⫽physical therapy, ICF⫽International Classification of Functioning, Disability and Health.