METHOD MODEL PRESENTATION
Development of a Clinical Reasoning Learner Blueprint:
A Guide for Teaching, Learning, and Assessment
Michelle Reilly, PT, DPT, Jennifer Furze, PT, DPT, Lisa Black, PT, DPT, Heather Knight, PT, DPT, CBIS,
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Jessica Niski, PT, DPT, Julie Peterson, PT, DPT, and Gail Jensen, PT, PhD, FAPTA
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Background and Purpose: Clinical rea-
soning (CR) is a foundational component
of effective and innovative physical thera-
pist practice. When considering the de-
velopment of the CR process over time, a
blueprint to guide both educators and stu-
dents along the learner continuum is valu-
able to the teaching and learning process.
is study describes the development of a
learner blueprint for CR to guide educators
in effective and evidence-based teaching,
learning, and assessment strategies.
Michelle Reilly is a board-certified specialist in
Orthopedic Physical erapy and assistant professor
at the Creighton University, 2500 California Plaza,
Omaha, NE 68178 (michellereilly@creighton.edu).
Please address all correspondence to Michelle Reilly.
Jennifer Furze is a board-certified specialist in
Pediatric Physical erapy and associate pro-
fessor at the Creighton University.
Lisa Black is a professor at the Creighton
University.
Heather Knight is a board-certified specialist in
Neurologic Physical erapy and assistant pro-
fessor at the Creighton University.
Jessica Niski is a board-certified specialist in
Pediatric Physical erapy and assistant pro-
fessor at the Creighton University.
Julie Peterson is a board-certified specialist in
Women’s Health Physical erapy and assistant
professor at the Creighton University.
Gail Jensen is a professor at the Creighton
University and adjunct professor of Medicine at
the Center for Health Professions Education
Uniform Services University of Health Sciences,
School of Medicine.
e authors declare no conflicts of interest.
Published Online First: December 22, 2021.
Received December 7, 2020, and accepted
September 22, 2021.
Supplemental digital content is available for this
article. Direct URL citations appear in the
printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web
site (www.aptaeducation.org).
Copyright © 2021 Academy of Physical erapy
Education, APTA
DOI: 10.1097/JTE.0000000000000217
Vol 36, No 1, 2022
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
Method/Model Description and Evaluation:
A 4-phased process was used to develop the
blueprint. Phase I (Critical literature review
and content analysis): A literature search to
identify articles relevant to the teaching,
learning, and assessment of CR across the
health professions was performed. Phase II
(Creation of draft blueprint): Investigators
reviewed all relevant articles, assigned them to
a learner level, identified common themes and
key concepts, and developed an overall sum-
mary statement of facilitation and assessment
strategies. Phase III (Expert Analysis/validation
and initial modification): Focus groups of
content experts reviewed the blueprint for
content, breadth, depth, and accuracy. Feed-
back from focus groups was used to inform
initial modifications to the blueprint. Phase IV
(Vetting of the blueprint with key stakeholders
and final modifications): Key stakeholders in-
cluding academic faculty, physical therapist
students, physical therapist residents, and
clinical instructors were recruited to review the
blueprint for utility and applicability. Feedback
from focus group data was used to inform a
second round of blueprint modifications.
Outcomes: After revisions based on the
analysis of the stakeholder focus groups, a
final blueprint was generated that repre-
sents linking learning theory with clinical
practice expectations in describing teaching
and learning strategies designed to facilitate
and assess CR across the continuum of
physical therapy education.
Discussion and Conclusion: e CR
learner blueprint can serve as a guide for
educators to facilitate and assess CR across
the educational continuum in both didactic
and clinical environments. Further analysis
and validation of the tool is needed.
Key Words: Clinical reasoning, Teaching,
Learning and assessment, Blueprint.
BACKGROUND AND PURPOSE
The Need for Adaptive Teachers
and Learners
Physical therapists are required to practice
efficiently and effectively while engaging in
Journal of Physical Therapy Education
innovative problem solving to address the
multifaceted challenges of clinical practice.1-5
Now more than ever, we need learners who
can not only think critically but are also
adaptive learners who develop life-long
learning skills, take responsibility for their
learning, engage in self-assessment, and con-
tinually work to improve themselves.2,6,7
While much is known about the science and
practice of how people learn, much more
work is needed in integrating learning science
concepts into the work of educators in both
informal and formal learning environments.8
We believe there is a gap between the educa-
tion we provide our physical therapist stu-
dents and the challenges of what society needs
from our clinicians.3,9,10
Traditionally, much of health professions
education, including physical therapy, focuses
on the development and application of
knowledge and facilitation of learners’ cog-
nitive processes.3 Work in the learning sci-
ences supports a broader view of learning
where the situated learning that occurs in a
clinical context provides a robust environ-
ment where social, cultural, and physical el-
ements are at work for all learners in the
community of practice.11 How do we as edu-
cators facilitate a teaching and learning envi-
ronment that connects these worlds?12-15
Although knowledge is essential in the
learning process, knowledge alone does not
adequately prepare the learner to adapt and
respond to novel patient situations. Pro-
fessional education must prepare adaptive
learners who will continue to learn and innovate
in response to challenging situations.1-3,16,17 is
requires a deeper understanding of the science
and practice of how learners learn.
Role of Clinical Reasoning in
Physical Therapy
Clinical reasoning (CR) is at the heart of a
clinician’s practice18 and development of CR
is at the heart of physical therapist education.
e challenges of health care and clinical
practice require physical therapists to use
high-order thinking skills, adaptability, and
effective CR to meet the needs of patients.
Clinical reasoning (CR) is a complex and es-
sential situation-dependent process that all
43
 health care providers engage in within the
context of clinical practice.18,19 Effective CR
requires the creation of narratives or inter-
pretations from multiple perspectives in-
cluding the health care provider, patient, and
workplace environment, to determine the best
course of action.19,20 Although CR is not new
to the health professions, it remains poorly
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understood and lacks clarity in both defini-
tion and description.18,21,22 While CR may be
seen as a defining characteristic of a health
profession, it is a complex, multifaceted phe-
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nomenon that continues to lead to confusion
about concepts and terminology.23 Addi-
tionally, many variables that could impact CR
(contextual factors, patient and provider af-
fect, and institutional factors) remain largely
underdeveloped in the literature.23
Huhn et al22 explored the CR process in
physical therapy taking a larger conceptual
view in investigating CR as a construct versus
a defined and concrete skill. Clinical reason-
ing should not be viewed as “just a skill” as
that definition implies a technical, applied
discrete ability without essential connections
to creation of knowledge and clinical perfor-
mance.18 Using this concept analysis, CR was
conceptualized as the integration of cognitive,
psychomotor, and affective skills that were
context dependent, collaborative with the
patient and therapist, and adaptive.22 A key
finding from the National Study of Excellence
in Physical erapist Education (NSPTE)
highlighted that while there was evidence of
faculty facilitating learners’ development of
CR, there was little evidence of pedagogy and
learning theory application that is critical to
developing adaptive learners with advanced
CR capacity across all learning environments
(academic, clinical, residency, and fellow-
ship).10,24 Educators face the challenge of de-
scribing, teaching, and assessing CR in
learners across the educational continuum
with strong pedagogical foundations.18,20
ere is a critical need for both academic and
clinical educators to understand teaching and
learning theories and to integrate them into
the teaching, learning, and assessment of CR
for all learners.10-12,17,24
Research by Christensen et al20 to evaluate
the implementation, teaching, and assessment
of CR further supports the need for a com-
prehensive approach to CR in physical ther-
apist education as recommended in the
NSPTE. Although CR has been identified as
essential to the work of a physical therapist, a
comprehensive approach for facilitating and
assessing CR across physical therapist edu-
cation programs has not been clearly estab-
lished.25-27 Research suggests CR has been
integrated into physical therapist education
program curricula; however, significant vari-
ability exists in the definition, teaching, and
44
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
assessment of CR across programs.20 A single
gold standard for assessing CR in physical
therapy does not exist and thus utilization of
multiple tools across time is warranted.28
Additionally, intentional teaching and learn-
ing strategies that progress the advancement
of the learner’s CR abilities over time with
appropriate strategies is needed.10,29
The Need for a Blueprint
When considering the complexities of the
development of the CR process over time,
educators and learners would benefit from
resources grounded in theory and evidence to
guide the teaching, learning, and assessment
of CR across a curriculum. A blueprint is a
method of content mapping that links as-
sessment to learning objectives and can serve
as a resource to inform the teaching and
learning process from start to finish while also
infusing the learning sciences into existing
evidence-based strategies. A blueprint for CR
in physical therapist education would allow
educators to assess the individual learner’s
current CR abilities and then individualize
teaching and learning strategies to facilitate
development over time. e development of
such a blueprint would be valuable to assess-
ment of workplace learning or clinical educa-
tion as well as competency-based education.30
Theoretical Constructs of Clinical
Reasoning Blueprint
e development of a blueprint to guide
teaching, learning, and assessment of CR was
organized around previously developed con-
structs that describe multiple dimensions of
clinical knowledge31 and a developmental
process of skill acquisition.32,33 Krathwohl31
describes 3 dimensions of knowledge: content
knowledge (factual information), procedural
knowledge (application of knowledge and
performance of skills), and metacognitive
knowledge or conceptual reasoning (re-
flection and integration of knowledge). e
Dreyfus and Dreyfus model of skill acquisi-
tion describes progression (from beginner to
intermediate to competent to proficient)
when learning or refining new skills32,33 and
has previously been used to describe clinical
development across time in health profes-
sions.34,35 ese domains of knowledge and
progression benchmarks were previously in-
tegrated into the Clinical Reasoning Grading
rubric,36,37 now referred to as the Clinical
Reasoning Assessment Tool (CRAT),38 which
is used to assess CR capacity across time in
physical therapist students and residents. e
CRAT serves as the organizational framework
for the development of the current blueprint,
creating 12 categories of evidence-based strat-
egies for teaching, learning, and assessment of
Journal of Physical Therapy Education
CR (each domain of content knowledge, pro-
cedural knowledge and skills, and conceptual
reasoning at each performance descriptor of
beginner, intermediate, competent, and pro-
ficient). rough identification of the stage of
the learner using the performance descriptors
(beginner through proficient) and target cate-
gory of CR (content knowledge, procedural
knowledge and skills, and conceptual reason-
ing), the educator can determine a starting
point and progression for the teaching, learn-
ing, and assessment of the CR process.
e purpose of this study was to describe
the development of a learner blueprint for CR
to guide educators in effective and evidence-
based teaching, learning, and assessment
strategies across the continuum of physical
therapist education (see Clinical Reasoning
Across the Continuum of Physical erapist
Education: A Blueprint for Teaching, Learn-
ing, and Assessment document, Supplemental
Digital Content 1 [SDC 1, http://links.lww.
com/JOPTE/A150]).
METHOD/MODEL DESCRIPTION
AND EVALUATION
Development of Clinical
Reasoning Blueprint
e development and validation of the blue-
print included 4 phases: critical literature re-
view and content analysis, creation of draft
blueprint, expert analysis/validation with
initial modifications, and vetting of blueprint
with key stakeholders with final modifica-
tions. ese phases are outlined in Figure 1.
is study was approved by the Creighton
University Institutional Review Board.
Phase I: Critical Literature Review and
Content Analysis
A search of the literature was conducted in
January to March 2018. MEDLINE, CINAL,
and ERIC databases were searched from 2000
to current using the key words: “assessment”
and “clinical decision-making” or “clinical
reasoning” or “critical thinking” and “health
professions.” A second search was completed
in August to September 2018 to ensure satu-
ration of literature. While not included in the
formal literature search, the research team
monitored newly published literature related
to these key search words from September
2018 to August 2020 to further inform the
refinement of the blueprint. Investigators
reviewed abstracts of 260 articles from all
health professions to determine appropriate-
ness of each article for inclusion in the blue-
print. Full-text articles of appropriate
abstracts were further reviewed for applica-
tion to teaching, learning, and/or assessment
of CR. e relevant literature was then
Vol 36, No 1, 2022
 Figure 1. Phases of Blueprint Development.
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categorized to performance descriptor (be-
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ginner, intermediate, competent, or proficient
level) and sorted into facilitation of CR versus
assessment of CR. Any literature that applied
to multiple descriptors was categorized in all
appropriate levels.
Phase II: Creation of Draft Blueprint
All literature classified to a specific perfor-
mance descriptor (beginner, intermediate,
competent, and proficient) was further in-
vestigated by 2 members of the research team
to identify common themes and key concepts
and to develop an overall summary statement
of CR facilitation and assessment strategies
for each level. Recommendations and specific
examples of evidence-based strategies for
each knowledge domain were also developed
by the 2-person team after the literature re-
view and were aligned with established
learning science theories. e summaries,
recommendations, examples, and relevant
learning science applications were discussed
by all members of the research team to con-
firm findings and come to consensus of the
draft CR blueprint. Visual representations
and tables were developed to further synthe-
size the literature and organize the perfor-
mance descriptor–specific summaries and
recommendations for a user-friendly format.
Phase III: Expert Analysis and
Validation of Blueprint with
Initial Modifications
After the draft blueprint was created, content
experts with established research in CR or
membership in a national CR special interest
group were identified through professional
networks. Eleven content experts with aca-
demic and/or clinical expertise were invited to
participate in 1 of 2 scheduled focus groups to
assess and validate the content of the blue-
print. Seven content experts (Table 1) agreed
to participate in validation focus groups based
on their personal availability and were pro-
vided with a draft of the blueprint via email to
review before the meeting. ere were 3 and 4
participants, respectively, in each phase III
focus group, which were held via video con-
ferencing software in April and May 2019.
Vol 36, No 1, 2022
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
Participants were provided with a small gift
card for participating in the focus group.
e intent of phase III focus groups was to
review the depth and breadth of content within
the blueprint. Semi-structured interviews were
used by 2 members of the research team to guide
the focus groups. Interview questions probed
the breadth and depth of CR literature in the
blueprint, identified omissions or oversights
related to content and organization, and soli-
cited recommendations for improvement of the
resource. e interviews with the focus groups
were recorded and professionally transcribed
and focus group leaders kept field notes. All
research team members reviewed data from the
transcripts and field notes. A phase III round-
table discussion with the full research team
allowed for consideration of the feedback from
the content experts. Group consensus of the full
research team was used to determine what
changes needed to be made to the blueprint. e
blueprint was revised based on the recommen-
dations of this phase before moving to phase IV.
Phase IV: Vetting of Blueprint With Key
Stakeholders and Final Modifications
Four groups of key stakeholders were identified
as target users for the blueprint to participate in
vetting of the blueprint for utility and appli-
cability: academic faculty, physical therapist
students, physical therapist residents, and
clinical instructors. Individuals from each of
these groups were identified and recruited
through professional networks. Eleven indi-
viduals responded to an initial invitation to
participate in 1 of 2 scheduled focus groups
according to their personal availability (5
clinical instructors, 5 students, and 1 academic
faculty member from an Occupational erapy
program). ere were 4 and 7 participants in
each focus group, respectively, and all partici-
pants were given the option to participate in
person or via an electronic meeting platform.
e 11 participants were provided with a draft
of the blueprint that included phase III revi-
sions to review before the meeting dates in
October and November 2019. Participants
were provided with a small gift card for par-
ticipating in the focus group.
e intent of this focus group was to
gather opinions related to overall format,
Journal of Physical Therapy Education
organization, and utility of the blueprint.
Focus group participants also provided rec-
ommendations to improve the blueprint and
discussed applicability to the stakeholder’s
role in physical therapist education. Semi-
structured interviews were used by 2 members
of the research team to guide the focus groups
with follow-up questions used as needed. In-
terviewers focused on questions that evalu-
ated overall usefulness of the tool and what
additional information was required to in-
crease usefulness of the tool. Each focus group
interview was recorded and professionally
transcribed and focus group leaders kept field
notes.
All research team members reviewed data
from the transcripts and field notes from phase
IV. e focus group leaders summarized the data
from the focus groups to lead a phase IV round
table discussion with the full research team.
Outcomes
e blueprint was revised after both phase III
and phase IV to incorporate feedback. Com-
ments and suggestions from focus group
participants were discussed by the full re-
search team before group consensus of the 7-
person research team was used to decide
which elements to incorporate into the blue-
print immediately versus elements that might
be appropriate for future efforts. Table 2
summarizes the outcomes and the overall
changes made to the blueprint based on
feedback for both phases.
Phase III: Feedback From
Content Experts
e goal of phase III focus groups was to
validate the content of the blueprint with
content experts and then revise the blueprint
based on their feedback. e first outcome
from phase III focus groups was that content
experts felt that adequate depth and breadth
of CR literature was represented in the blue-
print and that overall, the blueprint was
comprehensive and thorough if not over-
whelming in volume. Content expert feed-
back called for improved organization of
content to address the overwhelming volume
of information. In response to this feedback,
the blueprint was reviewed for areas of
45
 Table 1. Content Expert Description strategies for teaching, learning, or assessment of
CR, it was not included in the current blueprint.
Highest degree earned DPT: 42.9% (3/7) e final outcome from phase III focus
PhD: 57.1% (4/7) groups identified the need for increased clarity
Years of experience <10 y: 14.3% (1/7) related to (1) the role of the clinical instructor
10–19 y: 14.3% (1/7) and (2) the progression of the learner. Content
>20 y: 71.4% (5/7) experts felt that while strategies were appro-
priately assigned to learner categories, the role
Primary employment setting 28.6% Clinical practice (2/7)
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of the clinical instructor in using this resource

Authorship of peer reviewed research articles
related to clinical reasoning
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71.4% University (5/7)
to promote CR during clinical experiences was
71.4% (5/7) unclear. Additionally, the groups requested
improved clarity in how to progress the learner

ABPTS Certified clinical experts
Abbreviations: ABPTS = American Board of Physical Therapy Specialties; CCS = Cardiovascular and Pulmonary
Certified Specialist; GCS = Geriatric Certified Specialist; OCS = Orthopedic Certified Specialist; PCS = Pediatric
Certified Specialist.
unnecessary complexity or redundancy and
was edited as needed. Additionally, significant
reformatting attempts were made to re-
organize the content by including tables and
figures to make the amount of content more
accessible and reader friendly. An example of
the changes made after the phase III focus
groups can be seen by comparing SDC 2 and
SDC 3 (Supplemental Digital Content 2 and 3,
http://links.lww.com/JOPTE/A151 and http://
links.lww.com/JOPTE/A152), which high-
lights the additional visuals that were de-
veloped to demonstrate key points for each
level of the learner and the organization of
teaching and learning strategies into a table
57.1% (4/7, GCS, CCS, PCS, OCS)
format with references to decrease length and
narrative components.
e second outcome from the phase III focus
group was the identification of an omission of the
specific role of movement analysis and in-
terpretation as integral to clinical practice and
CR. Content experts recommended that move-
ment as a defining characteristic of the profession
be integrated into the blueprint at multiple levels.
e noted omission related to the role of
movement was considered after the research
team conducted further review of the literature.
A single article related to the role of movement
within CR was identified (Sebelski et al39);
however, because it did not identify specific
through the various performance domains (ie,
from intermediate to competent). In response
to this feedback, the research team augmented
the blueprint with specific examples for appli-
cation of blueprint strategies. Examples that
highlighted the clinical learning environment
and examples with demonstration of the level
of the learner were added to assist in the nav-
igation of the blueprint. e research team also
developed a “CR blueprint roadmap” (page 7,
SDC 1 [Supplemental Digital Content 1, http://
links.lww.com/JOPTE/A150]) to highlight the
cyclical process of assessing, using targeted
strategies, and then reassessing the learner to
further clarify the progression of the learner.
Phase IV: Feedback From
Key Stakeholders
e goal of phase IV focus groups was to
determine the usability, applicability, and

Table 2. Phase-Specific Focus Group Outcomes and Blueprint Modifications

Goals Focus Group Outcome Response to Feedback

Phase 3—Expert analysis and
validation of blueprint with
initial modifications
Phase 4—Vetting of blueprint
with key stakeholders and final
modifications
• Validation of the content of
the blueprint by content experts
• Revise blueprint based on
content expert feedback
• Determine usability,
applicability, and
appropriateness of overall
format
• Revise blueprint based on
stakeholder feedback
• Adequate depth and breadth
represented, but overwhelming
• Omission of movement as
defining characteristic
• Need for increased clarity
related to:
Role of the clinical instructor
Progression of the learner
• Need for increased clinical
examples to illustrate level of
the learner
• Need for enhanced
organization
• Need for condensed version to
facilitate utility
• Edited for unnecessary
complexity and redundancy
• Increased organization with
tables and figures
• Literature revisited to
investigate omission
• No new strategies identified
• Specific examples of
strategies applied to clinical
environment added
• Examples with demonstration
of learner level added
• Development of clinical
reasoning blueprint roadmap
figure
• Clinical examples clarified
and refined
• Additional examples
developed
• Reformatting of tables,
images, and addition of color
coding
• Various delivery models
considered for future projects

46 Journal of Physical Therapy Education Vol 36, No 1, 2022

Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
 Figure 2. Academic Example of Blueprint Application. PT = Physical Therapist
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appropriateness of the overall format of the
blueprint and then to revise the blueprint based
on their feedback. e first outcome from
phase IV was that stakeholders felt that the
blueprint could be applied in their respective
roles with improved understanding of the
level of the learner. However, stakeholders
requested more examples to illustrate the var-
ious levels of the learner. e research team
responded to this feedback by further refining
clinical examples within the blueprint. Existing
examples were clarified to indicate expected
performance at a given performance descriptor
and additional examples were developed.
e second outcome from phase IV focus
groups was continued need for enhanced or-
ganization to facilitate translation to practice,
even after the phase III revisions. Stakeholders
from phase IV suggested the development of a
condensed version for clinical practice, a
summary sheet of the CR blueprint for the

Figure 3. Clinical Example of Blueprint Application. PT = Physical Therapist; SNAPPS = Summarize, Narrow, Analyze, Probe,
Plan, Select

Vol 36, No 1, 2022 Journal of Physical Therapy Education 47

Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
 different stakeholders (academia vs clinical
educators vs students), a “checklist” as an ap-
pendix for assessing when CR tasks have been
achieved or instructional resources/videos for a
step-by-step process for use of the CR blue-
print. While there were numerous suggestions
for additional models of delivery, the research
team consensus was that these modified ver-
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sions would be appropriate for future work
after the full version of the blueprint was vali-
dated and published. e research team did
respond to this feedback by linking similar
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concepts within the blueprint, refining the
formatting of tables and images, and adding
color coding to established tables. An example
of the blueprint modifications made after this
series of focus groups can be seen by compar-
ing SDC 3 and SDC 4 (Supplemental Digital
Content 3 and 4, http://links.lww.com/JOPTE/
A152 and http://links.lww.com/JOPTE/A153),
which highlight color codes added both to level
of the learner and target domains as well as
links within the document.
DISCUSSION AND CONCLUSION
We developed a final blueprint that describes
teaching and learning strategies to facilitate
and assess CR that are appropriate across the
continuum of physical therapy learning (see
Clinical Reasoning Across the Continuum of
Physical erapist Education: A Blueprint for
Teaching, Learning, and Assessment docu-
ment, SDC 1 (Supplemental Digital Content
1, http://links.lww.com/JOPTE/A150), for the
final version of the blueprint). e de-
velopment of this blueprint heeds the call of
Jensen et al in the NSPTE9,10 and Christensen
et al20 to develop a comprehensive approach
to teaching, learning, and assessment of CR
while infusing the learning sciences into this
process through identification of cognitive or
knowledge factors as well as noncognitive
factors including context and culture.11,14
Focus group feedback from both content
experts and key stakeholders was beneficial in
refining the blueprint and increasing clinical
utility. Focus group participants found the
blueprint to contain a wealth of information,
however recommended significant work for
content reorganization and creation of ex-
amples. While the tool has evolved from its
initial iteration, continued evaluation and
evolution of the blueprint will be imperative
for integration into practice. e focus groups
used in this project to establish initial content
validity and usability can serve as a pilot for-
mat for larger scale validation measures.
is tool is an important initial step in
integrating learning theory concepts with
teaching and learning strategies. Our focus
group feedback is a critical element in ex-
ploring the potential for application of the
48
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
tool in both clinical and didactic arenas. Stu-
dents, clinicians, and faculty in the focus
groups commented on the potential use of the
blueprint in their specific settings and roles.
e shared terminology, expectations, and
strategies outlined within the CR blueprint
provide an opportunity for increased com-
munication and collaboration across clinical
and academic settings.20 Use of the blueprint
can provide a tie between didactic and clinical
education by facilitating discussions related to
student progression through shared un-
derstanding of best educational practices.10,20
e CR blueprint may be a useful guide to
assessment of learner performance by con-
necting teaching, learning, and assessment
strategies with learning objectives and can
help educators advance the learner across the
continuum of physical therapy education,
including residency education.30
is blueprint can be applied at the level of
the individual learner or cohort of similar
learners by assisting educators in identifying
strengths and gaps in CR, even in early stages of
learning, to create an educational diagnosis. By
identifying the specific deficits related to the CR
process, educators can choose learning experi-
ences to facilitate CR that are appropriate to the
level of the learner (beginner, intermediate,
competent, or proficient) and specific to the
individual learner’s knowledge gaps within CR
(content knowledge, procedural knowledge, and
conceptual reasoning), allowing for a targeted
approach to the development of CR abilities.40-
42
e blueprint can also be used to identify
learning strategies appropriate for learners per-
forming above their expected level to further
challenge and develop CR or to provide re-
mediation opportunities for those students who
are not meeting expectations.43 is results in
an approach to the teaching and learning of CR
that is learner centered and could enhance deep
learning with sustained conceptual un-
derstanding.41 Figures 2 and 3 provide examples
of how the CR learner blueprint can be applied
in academic and clinical settings, respectively.
Outcomes of the focus groups also high-
light the need to make resources like the
blueprint easy to access and digest. Both
phases of focus groups requested integration
of additional clinical examples to illustrate the
application of the blueprint and both focus
groups commented on additional methods to
provide condensed versions for various
stakeholders. Faculty, students, and clinicians
are burdened with multiple responsibilities
and rely on resources like the blueprint to
make their jobs easier not harder. To facilitate
integration into practice, continued work on
the blueprint will need to emphasize delivery
models that allow for quick reference and
application. Additionally, training in efficient
use of the blueprint through various
Journal of Physical Therapy Education
professional development courses could fur-
ther enhance the adoption of the tool.
With further assessment and validation of
the CR blueprint, this resource has potential to
influence physical therapist education beyond
application at the level of the individual learner.
e blueprint could influence curricular de-
velopment by providing a longitudinal plan for
learner development with learning experiences
that are appropriately leveled and establish
progressive increases in expectations. Applica-
tion of the blueprint across physical therapist
programs may reduce variability in the teaching,
learning, and assessment of CR, as well as pre-
sent opportunities for collaboration and co-
operation to further educational research in
physical therapy education around the concept
of CR. is blueprint could serve as a stepping-
stone to the development of entrustable pro-
fessional activities (EPAs) in physical therapist
education as part of a larger framework of
competency-based education.44 At this time, a
comprehensive assessment framework in
physical therapy education does not exist, al-
though a need has been demonstrated, and
EPAs lend themselves to competency-based
outcomes to measure learner performance
across the educational continuum.44
Limitations and Future Research
While the authors attempted to capture both
depth and breadth of CR literature across health
professions, the time between the conduction of
the search and the development of the blueprint
provides a window where some relevant and
important literature may have been missed.
Literature that emerged between the initial
search and the writing of this manuscript was
used to inform the background understanding
of CR, but no new literature was identified to
specifically change the teaching, learning, and
assessment strategies contained within the
blueprint. Of note related to the timeline of this
project is a gap around the description, identi-
fication, and integration of movement as a core
concept in CR as highlighted recently by
Sebelski et al,39 especially as it relates to the
theme of depth and breadth of content within
the blueprint. In their call to action, Sebelski
et al39 urge physical therapists to develop
evidence-based procedures and competencies
for movement and movement analysis, both
from the patient and therapist perspective, and
embed this within a physical therapy CR
framework. As research related to movement in
CR is expanded, these findings should be in-
corporated into the blueprint. is resource
highlights the continually evolving un-
derstanding of CR and ongoing research in the
field that will require regular updates to the
blueprint and creation of a living document to
maintain alignment with current best practices.
Vol 36, No 1, 2022
 Focus groups were used for validation and
vetting of the blueprint, using both experts in
the field of CR and key stakeholders. However,
focus group scheduling resulted in relatively low
numbers of participants. While physical thera-
pist residents were identified as a key stake-
holder group for blueprint use, we were unable
to recruit any residents to participate in phase
Downloaded from http://journals.lww.com/jopte by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
IV focus groups. Despite special efforts made to
recruit and invite participants who had a wide
range of experience with students of varying
abilities as well as students from outside pro-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/19/2023
grams, the phase IV focus groups represented
primarily students and clinicians affiliated with
our program, creating a relatively narrow geo-
graphical impact and the potential for bias in
this phase of the blueprint development. Be-
cause of these limitations in size and scope of
focus groups, additional validation and repli-
cation efforts should be made using large-scale
recruiting practices to support these results.
While many recommendations that resulted
from focus groups were applicable to the initial
development of the blueprint, many suggestions
for future development and utility of the blue-
print were highlighted. ese suggestions pro-
vide potential next steps for further refinement
and enhancement of clinical utility of the tool.
e depth of content within the blueprint was
also noted during all focus groups and a need for
training educators in appropriate use of the
document was highlighted. Efforts to educate
students, residents, clinicians, and academicians
on use of the blueprint will be vital in bringing
theory to practice. Future research should eval-
uate professional development methods imple-
mented to bring this knowledge to action.
Future research should continue to assess
clinical utility and outcomes of implementing
the blueprint. Learner-specific outcomes re-
lated to blueprint use and implementation
were outside the scope of the current project
but represent the primary drive for overall
development of the blueprint, and assessment
of these outcomes would be paramount in
showing clinical utility. Additionally, as the
blueprint has potential to steer curricular
change, programmatic outcomes related to
implementation of the blueprint would also
be of interest for future research.
FUNDING
is work was supported by an internal grant
from the Teaching and Learning Center,
Creighton University.
REFERENCES
1. Cutrer WB, Miller B, Pusic M, et al. Fostering
the development of master adaptive learners: A
conceptual model to guide skill acquisition in
medical education. Acad Med. 2017;92:70-75.
Vol 36, No 1, 2022
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
2. Horsfall D, Tasker D, Higgs J. Clinical decision
making, social justice and client empower-
ment. In: Higgs J, Jensen GM, Christensen N,
Loftus S, eds. Clinical Reasoning in the Health
Professions. 4th ed. Boston, MA: Elsevier;
2019:201-209.
3. Mylopoulous M, Kulamakan K, Woods N.
Developing the expertise we need: Fostering
adaptive expertise through education. J Eval
Clin Pract. 2018;24:674-677.
4. Magnusson DM, Rethorn ZD, Bradford EH,
et al. Population health, prevention, health
promotion, and wellness competencies in
physical therapist professional education: Re-
sults of a modified Delphi study. Phys er.
2020;100:1645-1658.
5. Xia R, Stone JR, Hoffman JE, Klappa SG.
Promoting community health and eliminating
health disparities through community-based
participatory research. Phys er. 2016;96:
410-417.
6. Ziebart C, MacDermid JC. Reflective practice
in physical therapy: A scoping review. Phys
er. 2019;99:1056-1068.
7. Wainwright SF, Shepard KF, Harman LB,
Stephens J. Novice and experienced physical
therapist clinicians: A comparison of how re-
flection is used to inform the clinical decision-
making process. Phys er. 2010;90:75-88.
8. National Academies of Sciences, Engineering,
and Medicine. How People Learn II: Learners,
Contexts, and Cultures. Washington, DC: e
National Academies Press; 2018. doi: 10.17226/
24783.
9. Jensen GM, Nordstrom T, Mostrom E, Hack
L, Gwyer J. National study of excellence and
innovation in physical therapist education:
Part 1—design, method, and results. Phys
er. 2017;97:857-874.
10. Jensen GM, Nordstrom T, Mostrom E, et al.
National study of excellence and innovation in
physical therapist education: Part 2—A call to
reform. Phys er. 2017;97:875-888.
11. Nathan MJ, Sawyer K. Foundations of the
learning sciences. In: Sawyer K, ed. e
Cambridge Handbook of the Learning Sciences.
2nd ed. New York, NY: Cambridge University
Press; 2017:21-44.
12. Mylopoulous M, Regehr G. Putting the expert
together again. Med Educ. 2011;45:920‐926.
13. Mylopoulous M, Regehr G. Cognitive meta-
phors of expertise and knowledge: Prospects
and limitations for medical education. Med
Educ [Internet]. 2007;41:1159‐1165.
14. Murphy P, Knight S. Exploring a century of
advancements in the science of learning. In:
AERA Review of Education Research. Vol 40;
2016:402-456.
15. Durning SJ, Artino AR. Situativity theory: A
perspective on how participants and the en-
vironment can interact: AMEE Guide no. 52.
Med Teach. 2011;33:188-199.
16. Mylopoulos M, Lohfeld L, Norman GR,
Dhaliwal G, Eva KW. Renowned physicians’
perceptions of expert diagnostic practice.
Acad Med. 2012;87:1413‐1417.
Journal of Physical Therapy Education
17. Cutrer W, Pusic M, Gruppen L, Hammoud
MM, Santen SA. e Master Adaptive Learner.
e AMA MedEd Innovation Series; 2020.
18. Trowbridge RL, Graber ML. Clinical reason-
ing and diagnostic error. In: Trowbridge RL,
Rencik JJ, Durning SJ, eds. Teaching Clinical
Reasoning: ACP Teaching Medical Series.
Philadelphia, PA: American College of Phy-
sicians; 2015:1-5.
19. Radcliffe TA, Durning SJ. eoretical concepts
to consider in providing clinical reasoning
instruction. In: Trowbridge RL, Rencik JJ,
Durning SJ, eds. Teaching Clinical Reasoning:
ACP Teaching Medical Series. Philadelphia,
PA: American College of Physicians; 2015:
13-17.
20. Christensen N, Black L, Furze J, et al. Clinical
reasoning: Survey of teaching methods, in-
tegration, and assessment in entry-level
physical therapist academic education. Phys
er. 2017;97:175-186.
21. Musolino GM, Jensen GM. Clinical reasoning:
Why it matters. In: Musolino GM, Jensen GM,
eds. Clinical Reasoning and Decision-Making
in Physical erapy: Facilitation, Assessment,
and Implementation. orofare, NJ: Slack Inc;
2020:3-7.
22. Huhn K, Gilliland SJ, Black LL, Wainwright
SF, Christensen N. Clinical reasoning in
physical therapy: A concept analysis. Phys
er. 2019;99:440-456.
23. Gruppen LD. Clinical reasoning: Defining it,
teaching it, assessing it, studying it. West J
Emerg Med. 2017;18:4-7.
24. Jensen GM, Nordstrom T, Hack L, Gwyer J,
Mostrom E. Educating Physical erapists.
oroughfare, NJ: Slack Inc; 2019.
25. Christensen N, Nordstrom T. Facilitating the
teaching and learning of clinical reasoning. In:
Jensen GM, Mostrom E, eds. Handbook of
Teaching and Learning for Physical erapists.
3rd ed. St. Louis, MO: Elsevier; 2013:183-199.
26. Durning S, Artino AR, Pangaro L, van der
Vleuten C, Schwirth L. Context and clinical
reasoning: Understanding the perspective of
the expert’s voice. Med Educ. 2011;45:927-938.
27. Durning SJ, Rencic JJ, Trowbridge RL,
Schuwirth L. Afterword: Teaching clinical
reasoning - Where do we go from here? In:
Trowbridge RL, Rencik JJ, Durning SJ, eds.
Teaching Clinical Reasoning: ACP Teaching
Medical Series. Philadelphia, PA: American
College of Physicians; 2015:253-255.
28. Furze J, Wainwright SF, Black L, Christensen
N. Assessment of clinical reasoning: Strategies
across the continuum of professional and post
professional physical therapy education. In:
Musolino GM, Jensen GM, eds. Clinical Rea-
soning and Decision-Making in Physical
erapy: Facilitation, Assessment, and Imple-
mentation. orofare, NJ: Slack Inc; 2020:
183-189.
29. Black L, Christensen N. Facilitation of clinical
reasoning: Teaching and learning strategies
across the continuum of learners. In:
Musolino GM, Jensen GM, eds. Clinical
49
 Reasoning and Decision-Making in Physical
therapy: Facilitation, Assessment, and Imple-
mentation. orofare, NJ: Slack Inc; 2020:
177-181.
30. McBride ME, Adler MD, McGaghie WC.
Workplace-based assessment. In: Yudkowsky
R, Park Y, Downing S, eds. Assessment in
Health Professions Education. 2nd ed. New
York, NY: Routlege, Taylor, & Francis Group;
Downloaded from http://journals.lww.com/jopte by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
2020:160-165.
31. Krathwohl D. A revision of bloom’s taxon-
omy: An overview. eor Pract. 2002;41:
212-217.
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/19/2023
32. Dreyfus SE, Dreyfus HL. A Five-Stage Model of
the Mental Activities Involved in Directed Skill
Acquisition. AD-A084-551 Ed. Berkeley CA:
Operations Research Center, University of
California Berkeley; 1980.
33. Dreyfus HL, Dreyfus SL. e relationship of
theory and practice in the acquisition of skill.
In: Benner P, Tanner CA, Chelsa CA, eds.
Expertise in Nursing Practice. New York, NY:
Springer; 1986:29-48.
34. Carraccio CL, Benson BJ, Nixon LJ, Derstine
PL. From the educational bench to the clinical
bedside: Translating the Dreyfus developmental
50
Copyright © 2021 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
model to the learning of clinical skills. Acad
Med. 2008;83:761-767.
35. Benner P. Using the Dreyfus model of skill
acquisition to describe and interpret skill ac-
quisition and clinical judgement in nursing
practice and education. Bull Sci Technol Soc.
2004;24:188-199.
36. Furze J, Black L, Hoffman J, Barr JB, Cochran
T, Jensen G. Exploration of students’ clinical
reasoning development in entry-level physical
therapy education. J Phys er Educ. 2015;29:
22-33.
37. Furze J, Black L, Cochran T, Gale J, Jensen G.
Clinical reasoning: Development of a grading
rubric for student assessment. J Phys er
Educ. 2015;29:34-45.
38. McDevitt A, Rapport MJ, Jensen G, Furze
JA. Utilization of the clinical reasoning as-
sessment tool across a physical therapy
curriculum application for teaching, learn-
ing, and assessment. J Phys er Educ. 2019;
33:335-342.
39. Sebelski CA, Hoogenboom BJ, Hayes AM,
Bradford EH, Wainwright SF, Huhn K. e
intersection of movement and clinical rea-
soning: Embodying “body as a teacher” to
Journal of Physical Therapy Education
advance the profession and practice. Phys
er. 2020;110:201-204.
40. Steinert Y. e “problem” learner: Whose
problem is it? AMEE guide no. 76. Med Teach.
2013;35:e1035-e1045.
41. Blumberg P. Developing Learner-Centered
Teaching: A Practical Guide for Faculty. San
Francisco, CA: Jossey-Bass; 2009.
42. Audetat MC, Laurin S, Dory V, Charlin B,
Nendaz MR. Diagnosis and management of
clinical reasoning difficulties: Part I. Clinical
reasoning supervision and educational di-
agnosis. Med Teach. 2017;39:792-796.
43. Audetat MC, Laurin S, Dory V, Charlin B,
Nendaz MR. Diagnosis and management of
clinical reasoning difficulties: Part II. Clinical
reasoning difficulties: Management and re-
mediation strategies. Med Teach. 2017;39:
797-801.
44. Chesbro S, Jensen GM, Boissonnault W.
Entrustable professional activities as a frame-
work for continued professional competence:
Is now the time? Phys er. 2018;98:3-7.
Vol 36, No 1, 2022