Impact of clinical education (escape room) on clinical reasoning skills of first year

DPT students

By: Ciara Charlick, Elliah Redden, & Timothy LaPointe

Central Michigan University, Mt. Pleasant.
8/2/23
 Abstract:

INTRODUCTION: The need for clinical reasoning has increased in physical therapy due to
advancements of educational requirements and the implementation of nationwide direct access.
Many universities have struggled to find consistency with assessment of clinical reasoning due to
its complexity of its definition. Research on clinical reasoning for healthcare students has been
completed in the past, however studies have not quantified improvements. The objective of this
study is to assess the impact of clinical education, including the escape room, on clinical
reasoning skills of first year students in Doctor of Physical Therapy (DPT) programs.

METHODS: This study will include 60 DPT students from Central Michigan University (CMU)
that have not previously taken the Clinical Education course, are in good academic standing, and
enrolled in all required courses. The students’ clinical reasoning will be evaluated before and
after the spring semester using the Watson-Glaser Critical Thinking Assessment tool (WGCTA).
The scores will be used to compare for a significant difference.

RESULTS: It is anticipated that the scores on the WGCTA will significantly improve after the
spring semester. The mean scores and individual categories are predicted to improve. This
finding will confirm that the clinical education course, escape room, and supporting courses help
develop the clinical reasoning skills of the students prior to their first clinical rotation.

CONCLUSION: The results of this study will provide DPT programs with information on
positive influences of clinical reasoning growth in students. This should encourage more
research into specific class scheduling to maximize students’ clinical reasoning growth prior to
graduation.

Keywords: clinical reasoning, physical therapy students, Watson-Glaser test

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INTRODUCTION
In 2009, it became a statewide requirement that any individual practicing physical
therapy in Michigan must possess a doctorate level education from a nationally accredited
program.1 Increasing the level of education necessary to practice elevates the importance of the
ability to think critically, in order to achieve the best care for patients and recognize differential
diagnoses within the scope of physical therapy.2 Furthermore, in 2015, Michigan became a direct
consumer access state for physical therapy services which brought the profession into a more
autonomous practice.3 The likelihood of seeing patients with less physician referrals and more
complex diagnoses increased, thus adding to the importance of clinical reasoning skills in the
field of physical therapy.
Clinical reasoning in physical therapy is an in depth, abstract process that includes
problem solving and integrating relevant information to evaluate, diagnose, and treat patients.4,5
Research within the last decade has shown that we have a significantly better understanding of
what factors make up clinical reasoning.6 Assessment of clinical reasoning involves both the
utilization of didactic knowledge and one’s own ability to problem solve.7
Integration of clinical reasoning skills has been a focus for Doctor of Physical Therapy
(DPT) curriculums over the past few years. Commission on Accreditation of Physical Therapy
requires accredited programs to teach and appraise clinical reasoning skills. Even with this
requirement, there is little research on the best educational approach to gauge improvements in
clinical rationale.8 The main focus of integrating clinical reasoning skills has been to increase
student’s understanding, reflecting, and applying the new information presented.9 This has been
achieved through consistent repetition of skills and providing students with opportunities for
continuous use of the clinical reasoning process.10 Research has shown that the greatest
improvements in clinical reasoning occurs during didactic learning compared to clinical
experience.8,11 Many DPT programs include classes that improve and assess clinical reasoning
skills throughout the program.12 These classes are referred to as clinical education courses and
can be taught in different formats, and include escape rooms, discussion groups, case reports, and
acting out real-life patient scenarios.
Even though clinical reasoning is perceived as a key skill in physical therapy, most
institutions find it hard to describe what that looks like in students. This leads to discrepancies
when teaching and researching this topic.13 Therefore, addressing this research topic is novel and
distinct. To address the need for additional research, the Watson-Glaser Critical Thinking
Assessment tool (WGCTA) clinical reasoning assessment tool will be used to quantify the skills
of current physical therapy students at Central Michigan University (CMU). The information
discovered in this study will help evaluate if the clinical education portion of DPT curriculum
adequately equips students’ clinical reasoning skills for their first clinical experience. Therefore,
the objective of this study is to assess the impact of clinical education, including the escape
room, on clinical reasoning skills of first year DPT students. The results can help develop a
curriculum that best grows and assesses clinical reasoning skills in physical therapy students
across the United States.

METHODS
The most clinical reasoning that occurs within DPT programs occurs through clinical
education courses. This study will be conducted through the DPT program at CMU and the
clinical education portion of the curriculum during the first year will be used as an educational
model. In CMU’s DPT program, there is a 16 week course that takes place in the spring semester

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of the first year and it is structured to integrate the clinical reasoning skills learned throughout
the semester through simulated practice. The courses for the first year spring semester of the
DPT program at CMU, which includes the course that aims to improve clinical reasoning skills,
can be found in Figure 1. Examination and Diagnosis II and Clinical
Pathophysiology/Pharmacology II build upon student’s knowledge of differential diagnosis. In
these courses, students learn about a variety of pathologies, how to recognize their signs and
symptoms, and how to differentiate between them to identify impairments that need to be treated.
Therapeutic Interventions and Clinical Anatomy and Kinesiology of Human Joints involves
critical thinking skills to create individualized treatment plans, as students learn the
osteokinematics and arthrokinematics of the joints in the human body that determine different
treatment techniques. Clinical Education I provides the environment for students to integrate
critical reasoning skills they have gained into practice through simulated patient cases.14 Students
are required to complete documentation for each patient case to apply their critical thinking,
which requires the ability to sort through information to find what is relevant and develop a plan
of care. Clinical Education I utilizes an escape room activity that attempts to assess student’s
clinical reasoning abilities at the beginning and end of the semester. The full Clinical Education I
course description can be found in Figure 2. Each week, students are presented with patient
cases, where they must use the techniques learned throughout their courses to evaluate, diagnose
and treat impairments.
The escape room is performed during the first week of the semester and again during the
last week, to gauge where students are with their skills when they start compared to when the
semester is finished. In this activity, students are randomly assigned into groups of 4 and must
work together to solve puzzles by obtaining information and performing techniques on a
standardized patient. Each group is given an hour to obtain subjective information and past
medical history from the standardized patient to get a full picture of what is going on with the
patient. The students will perform diagnostic tests to identify impairments and develop a plan of
care. They will also provide some treatment to these standardized patients. When the correct
questions are asked, correct special tests completed, or proper treatment identified, the students
receive a notecard with clues to solve 5 puzzles that range from crosswords to solving riddles.
Utilizing an escape room in this course is a way to apply didactic knowledge by imitating
interdisciplinary collaboration and working on immediate recall, but in a game-like format that
keeps students engaged.15,16 The escape room, when used in conjunction with the coursework of
the same semester, is used to improve clinical reasoning skills, however the escape room is not
able to do this as a standalone event. The escape room itself is not graded and does not provide
the students with clinical reasoning skills, but allows students to apply and practice what they
have learned from the other courses.
There are many clinical reasoning assessment tools available for use that attempt to
measure changes in an individual's level of critical thinking. One clinical reasoning assessment
tool that has been used in previous studies is the Watson-Glaser Critical Thinking Appraisal Test
(WGCTA). The WGCTA was designed for students to: “analyze, reason, interpret, and draw
logical conclusions from written information.”17(p2) This test has been shown to have reliability,
internal consistency, and validity.18 Though research has been done using the WGCTA, limited
data has been collected on the curricular effects of clinical reasoning for physical therapy
students. The third version of the WGCTA is a timed 30-minute, online, 40 question multiple
choice test that is divided into five sections: inferences, recognition of assumptions, deductions,
interpretations, and evaluation of arguments. The older second version of the WGCTA is a

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proctored and untimed test, however the third version, which was introduced to the United States
in 2018, will be used as it is a timed test that will require more skill to think critically while
under a time constraint. The third version of the WGCTA also has a large question bank so each
individual will have a different version of the test, but the same level of difficulty for each
question will assimilate so it will remain standardized. The differences between each version of
the test can be seen below in Table 1. Version three of the WGCTA utilizes the Recognize,
Evaluate and Draw conclusions (RED) model of critical thinking which focuses on three main
categories of critical thinking: recognizing assumptions, evaluating arguments, and drawing
conclusions. The recognizing assumptions category focuses on the individual's ability to
comprehend and correctly identify true information versus assumptions while the category of
evaluating arguments centers on the ability to remain objective and reasonably work through
evidence and arguments. The final category, drawing conclusions, hones in on logical rationale
based on evidence to lead to different conclusions.19 The results from the WGCTA test give both
a profile report, which includes the number of correct answers, and a developmental report,
which highlights individuals areas of strength. The profile report will rank each individual and
give an overall percentile score based on the difficulty of each question and is split into the three
categories from the RED model. The development report marks the individual area of strength
for each individual for all three categories as either strength to leverage, further exploration, or
opportunity for development. The results can then be used to highlight specific areas needed for
growth for each participant.20 An example of a question that could be asked on the WGCTA can
be seen below in Figure 3.
The initial sample size of this study will include a total of 60 participants from CMU’s
first year DPT program, which is the typical class size that will be performing in the escape
room. The participants will be both male and female students above the age of 18 and will need
to meet the following inclusion criteria: must be enrolled in the DPT program at CMU in all
courses, has not previously completed the escape room for Clinical Education I, has not
previously taken the WGCTA, is in good academic standing with a grade point average of at
least a 3.0, has no cognitive impairments, and has access to a computer to take the WGCTA
online.
Participants will be recruited through a mass email sent out to all of the first year students
and an announcement will be given to the students before the first escape room and after their
second escape room of the Clinical Education I course. Once the participants read the email or
receive the in-person announcement and complete the consent forms, the participants will
complete the WGCTA and be included in the study. All identifiable participant information will
be protected and kept confidential.
Since the WGCTA third version is an online formatted test, the research participants will
be able to take it at a convenient time for them. We can distribute the access to the test via email
with a description of the requirements of the test and instructions on how to take it. No phones
should be used during any portion of the test and the test should be taken individually, which will
be explained in the email. The results should be sent back automatically, but in the case they are
not, instructions on how to send the results back will be included and multiple reminder emails
will be sent out.

Statistical Analysis
A paired T-test will be used to compare individual scores in separate categories on the
WGCTA completed before and after the spring semester. Significance level will be set at 0.05.

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This will provide insight to specific components of clinical reasoning that the courses may
highlight better than others.

RESULTS
This study assesses the impact clinical education has on clinical reasoning skills in first
year DPT students. It is anticipated that all participants will complete the WGCTA test before
and after the spring semester. It is projected that there will be a significant difference in overall
mean scores on the WGCTA after completing the spring semester, which includes the escape
room, and supporting courses. It is also predicted that all three models of critical thinking will
improve significantly. However, it is possible that some students may not make a significant
improvement due to lack of engagement throughout their courses. As students are exposed to
weekly cases that mimic real life patient scenarios, their clinical reasoning skills are expected to
improve. Overall, it is anticipated that clinical education and the escape room will be effective in
increasing clinical reasoning skills for first year DPT students.

DISCUSSION
All categories of the RED model are expected to improve from the first WGCTA test to
the second, indicating that there is a significant impact of the clinical education course and the
escape room in regards to clinical reasoning skills in first year DPT students. The recognizing
assumptions category will improve due to students learning how to differentially diagnose
patients using all information provided to them, since the coursework includes a lot of time spent
on pathophysiology and special tests to rule pathologies in or out. The evaluating arguments
section will improve because students will learn how to logically structure and work through
information, practiced through in-class demos and practicals. Lastly, the drawing conclusions
section will improve because students will learn how to sort through relevant information in
order to come to a rational verdict, which are skills the students work on during written
examinations and during practice evaluations. Literature supports the use of interactive learning
environments to help develop clinical reasoning skills in DPT students.15,16 The results from the
WGCTA test will highlight areas of growth necessary for each student that they can utilize in
their clinical experiences and throughout the rest of the program. The proposed study will obtain
results that will provide new insights into how critical thinking skills are improved most
effectively within DPT school curriculum.

CONCLUSION
A potential limitation to this novel study includes the 30 minute time limit on the test.
The results may be skewed if questions are left unanswered. The test does not adjust for those
who require testing accommodations, which may also result in questions not being completed to
the full extent. Another issue lies in the reliability of the student taking the test for a second time
at the end of the semester. It may be difficult to get each student who took it the first time to take
it a second time, since this would have to take place during the student’s final exam week. To
recruit these students again, we can send a follow up email explaining the need for anyone who
took the test once to take it again for any of the results to count.
To add, this study only focuses on one semester during the first year of CMU’s DPT
school that includes clinical education and an incorporation of an escape room instead of
reporting on the entirety of the program. A practical suggestion to improve this study would be

5
to incorporate the test in more areas of the program. Possible additions of the test could be
administered upon entry to the program, return from each clinical experience, and at the
completion of the program to study the impact of the program as a whole on clinical reasoning
skills. Branching out to administer the test at other universities may also be a practical suggestion
for the future to further gauge the impact of clinical reasoning skills on physical therapy students.

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Table 1. Differences between versions of the WGCTA

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Figure 1. CMU DPT Spring semester courses

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Figure 2. Clinical Education course description

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Figure 3. WGCTA test practice question

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