The Iterative Nature of Grounded Theory and Case Study Work, There is much debate concerning rigor in qualitative research.47 In our study, a range of strategies were used to strengthen the integrity of the study's findings. Epub 2020 Feb 7. These skills or strategies range from the act of making a diagnosis through management issues through ethical decision making. Geertz , Barrow EM. Danielle said nothing. Each conceptual framework is the result of a continued refinement of data collection, data analysis, and reference to existing theories in various fields of relevant literature. . Feltovich , Titchen A. Schmidt Mezirow Examples of knowledge organization used in clinical reasoning include “illness scripts”11 and “pattern recognition.“12,13 In making use of illness scripts or pattern recognition, the clinician recognizes certain features of a case almost instantly, and this recognition leads to the use of other relevant information, including “if-then” rules of production, in the clinician's stored knowledge network.14 This form of reasoning moves from a set of specific observations toward a generalization and is known as “forward reasoning.“12 Forward reasoning contrasts with hypothetico-deductive reasoning where a person moves from a generalization (multiple hypotheses) toward a specific conclusion.14 Experts generally agree that both forms of this cognitively oriented reasoning are used at different times.10,15 Pattern recognition is faster and more efficient and is used by expert and experienced practitioners in their domain.14 Hypothetico-deductive reasoning is used by more inexperienced practitioners and by experts when faced with an unfamiliar problem or a more complex presentation.10,15 These 2 cognitively oriented methods taken together are often referred to as “diagnostic reasoning.”4,5,16,17, Until the mid-1990s, the forms of clinical reasoning discussed were the main forms of reasoning described in the physical therapy literature. This process includes not only data collection but also the initial processes of coding. We found that all of the observed physical therapists in each of the 3 settings used a range of clinical reasoning skills or strategies representing a diversity of thinking and actions in a variety of tasks and relating to many issues that exist in clinical practice. This will facilitate efficient and effective decision-making by the clinician to optimize outcomes … Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences. Reasoning about procedure is the decision making behind the determination and carrying out of treatment procedures. Researchers of expertise and clinical reasoning in physical therapy,18–20 nursing,21–26 and occupational therapy27–31 then began to consider alternative methods for studying the development of expertise and the nature of clinical reasoning. On the one hand, there is ethical decision making as the application of normative or professional rules and principles to particular situations in a deductive or instrumental manner. A major source of ethical dilemmas in clinical practice revolved around problems associated with resource allocation. YS There were positivistic methods (eg, coding reliability) juxtaposed with naturalistic methods (eg, thick description). THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT. Sometimes this was done to gain the confidence of the patient or facilitate the engagement of the patient in the treatment session. J: That's because I was told that I would have—might have—a minor stroke, and I don't think this is …. eCollection 2019. Crepeau . Husband and wife related what each was doing now. This meant that when listening to the audiotapes later, there was a written commentary supplying both contextual information and a workable “index” to material on the audiotapes—an important factor for coding and the later construction of case studies. A number of different reasoning strategies were evident within the expert case studies and identified as being common to the practice of all of the physical therapists across the 3 fields. The breadth and variation in the skills required, as the demands of each area are considered, is vast. The purpose of this qualitative study was to examine the clinical reasoning of expert physical therapists in 3 different fields of physical therapy: orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (home health) physical therapy. There is no question that the physical therapists in our study often appeared to socialize or interact with their patients out of pure enjoyment. . A panel of 3 coders examined transcripts reflecting what occurred during treatments and interviews and coded them for clinical reasoning strategies, knowledge frameworks, and sources of knowledge. The remaining monographs each cover a major joint region of the body, from the cervical spine and temporomandibular joint to the foot and ankle. The treatment atmosphere had been loud (particularly on Narelle's part) and also action filled. We also sought to develop a new model to explain the clinical reasoning already in use among physical therapist clinicians. The aim of this third wave of data collection were to see whether data in the form of responses and themes began to recur.52 The data from the second sample were incorporated in the composite case studies representing each field to provide further commentary or corroboration of the data from the primary sample. A model of clinical reasoning in physical therapy characterized by the notion of "clinical reasoning strategies" is proposed by the authors. L When Narelle returned, she got in very close, softened her voice, and cradled N's left arm without speaking further for a short time. Following assessment of symptom behavior, T undresses, and “ropes” of paraspinal muscle spasm are noted by Michael. The hypothetico-deductive model remains the most enduring clinical reasoning model in medicine and was derived from a cognitive science perspective.10In the hypothetico-deductive method, the clinicians attend to initial cues (informa… P P On reassessment of lumbar flexion movement, both patient and therapist agree that it is substantially better, although T is still tense and in pain. Corkery MB, Hensley CP, Cesario C, Yen SC, Chui K, Courtney C. J Man Manip Ther. In arriving at this model, the data concerning clinical reasoning strategies and therapists' use of knowledge has, in the manner of grounded theory, been repeatedly compared and reapplied to existing theories or literature in relevant areas such as clinical reasoning, paradigms and typologies of knowledge, and the more formal theories such as Habermas' “Critical Social Theory”33 and Mezirow's “Transformatory Learning Theory.”35 Our model draws on these theories but in a manner that recontextualizes them in relation to the data of this study in particular and the scope of clinical reasoning in physical therapy in general. The nature of certain procedures precluded—apart from a more generalized consent or imprimatur—the therapist consulting the patient or asking his or her permission at every decision point. The research approach we used follows that of Jensen et al.18 Using a grounded theory, case study approach within an interpretive research paradigm (explained in the “Method” section), Jensen and colleagues were the first researchers to systematically study the clinical work of physical therapists in order to differentiate novice practitioners from their expert counterparts. The scope of teaching included information provision, instruction, advice (including informal counseling), and explanation. The APTA Michigan is a professional organization representing physical therapists, physical therapist assistants and students who have joined together to assure that high ethical professional standards are maintained and that quality health care in the areas of prevention, education and rehabilitation of movement dysfunction and wellness are received for all consumers in the state of … Higgs and Jones1 have defined clinical reasoning as a process in which the therapist, interacting with the patient and others (such as family members or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgment and knowledge. Clinical reasoning remains a relatively under-researched subject in physical therapy. J: Well, I've suffered from headaches since I was 16, well over 30 years, and I'm sure it must have been my aneurism. Metacognitive development. C By the end (perhaps 10 minutes), Mrs G was able to give gentle expression to the tears that had been rising but held so far during the visit. S The knowledge frameworks and sources of knowledge coding definitions were adapted from Jensen et al.19(p71) The knowledge framework codes included physical therapists' content knowledge of their field or speciality, their knowledge of patients (including of human behavior), a knowledge of teaching, a knowledge of self (including evidence of reflective ability, confidence, and growth as a person and as a professional), and a knowledge of context (relating more to understanding the larger picture and the role of their work, the work environment, and the workings of the health care system). Her published educational research centers around clinical reasoning, effective teaching methods, and pediatric physical therapy education. These therapists were a convenience sample50 of expert therapists who were involved in teaching in one of the relevant 3 practice areas through the University of South Australia. J: Got a long way to go, and it's been 3 years … and him and his brother had tests to see if it's hereditary, and they said, “You've got no worries.”. strategies [5]. JA . J MH Narelle appears to act from these principles, and yet there is that self-revelation both at the beginning and near the end of the interaction that personalizes her perspective. Previous clinical reasoning literature has proposed different reasoning processes for particular tasks in clinical practice (eg, procedural [ie, doing something to the patient] reasoning versus interactive [ie, knowing the patient] reasoning).26,28 We found that there was an interplay of different reasoning processes in every task of clinical practice, suggesting both a complexity and scope of clinical reasoning activity not previously understood. 7. AS 2004 Oct;84(10):984; author reply 984-5; discussion 985-7. These therapists used these reasoning strategies in an interplay that was governed by particular patients' needs and their contexts. The clinical reasoning strategies of interaction, procedure, teaching, collaboration, prediction, and ethics represent foci of clinical decision making or action in areas of patient management that may be oriented in either paradigm at particular times within a clinical encounter. Sometimes we get into the habit of just gritting our teeth and … keeping going when we're in pain. All clinicians, therefore, have an interest in improving their decision making. Predictive reasoning is the active envisioning of future scenarios with patients, including the exploration of their choices and the implications of those choices. Personal knowledge is experiential knowledge that comes about through the practitioner's reflection on experience (both work and non–work related) and helps form a practitioner's frame of reference or worldview with its particular values. Man Ther. Although 2 or more clinical reasoning strategies may be in operation concurrently and there may be overlap between the reasoning strategies (eg, interaction and collaboration), each clinical reasoning strategy requires an orientation of thinking and action, which is not wholly subsumed by the others. Just think about rotating at the elbow. . The visit had been very problem oriented, without any particular expression of how Mr G or his wife was feeling about the situation. This course begins the development of critical thinking and reasoning strategies through clinical presentations and management. From these composite case studies, cross-case analysis, first within settings and then across settings, was performed. The therapists were asked the same sample questions regarding issues of practice as those that the therapists in the primary sample were asked. , Jones MA. Thank you for submitting a comment on this article. The need for these data had been identified by the research panel in the process of the initial coding and data analysis about 4 months after the first data collection period and was based on a preliminary identification of diverse sources of knowledge being used in practice. Prediction included such decisions as when athletes could return to their sport or when injured workers could return to their jobs. , Tanner C, Chelsa C. Mattingly  |  The dialectical model of clinical reasoning arising from our study is depicted as reasoning that moves between those cognitive and decision-making processes required to optimally diagnose and manage patient presentations of physical disability and pain (hypothetico-deductive or instrumental reasoning and action) and those required to understand and engage with patients' (or caregivers') experience of that disability and pain (narrative or communicative reasoning and action). Edwards and colleagues 6, 11 explored the nature of expert clinical reasoning with their research-derived model of clinical reasoning strategies. Not only were the early studies of clinical reasoning in physical therapy more concerned with the diagnostic process, the majority of these studies were carried out in orthopedic settings.4,5,18,41–45 Physical therapist practice, however, occurs across a wide spectrum of health care and, as a profession, requires solving complex and poorly defined practice problems.36 In an Australian setting alone, a person could consider the range of skills needed, to do rehabilitation among aboriginal people in remote areas, cardiothoracic physical therapy in an acute hospital, orthopedic (manual) physical therapy in a private practice, physical therapy for children with orthopedic problems, or physical therapy aimed at helping retrain motor skills in adults following a stroke. Construct Validity of the Observable Movement Quality Scale in Pediatrics: Hypothesis Testing of a Formative Measurement Model. Clinical Reasoning and Decision Making in Physical Therapy: Facilitation, Assessment, and Implementation fills this need by providing a comprehensive and in-depth focus on development of the patient-client management skills of clinical reasoning and clinical decision-making. . Guided by a grounded theory method, a multiple case study approach was used to study the clinical practice of the 6 physical therapists in the 3 fields. J A J: But I mean if I had the ultimatum, what do I do? The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). Narelle: But a lot of people never have problems, but just occasionally people will. I couldn't really comment. P Narelle: Well, my mum's father died of one, and my sister's had one, so … [with an ironic laugh] they do run in families unfortunately. RK Here pain was metaphorically manipulated as a variable in the intervention that was carried out. Narrative reasoning involves the apprehension and understanding of patients' “stories,” illness experiences, meaning perspectives, contexts, beliefs, and cultures. A strong theme in the earlier part of this initial session had been M's poor coping mechanisms and unresolved conflict with other family members. It is not only this transfer of meaning (ie, where the intentions of the therapist and the perspectives of the patient are communicated and mutually understood) but also the transfer of power (ie, the therapist's letting go of a professional “right” to be right in favor of the patient's assumption of a greater voice) that constitutes the move to a communicative approach to collaboration. 2000 Jan;80(1):28-43; discussion 44-52. The data reduction and analysis for the study was organized around a set of cognitive processes identified by Morse53(p27): (1) comprehending, (2) synthesizing, (3) theorizing, and (4) recontextualizing. Abstract Background and purpose: Clinical reasoning is essential to physical therapist practice. , Huberman AM. Outside of diagnosis, hypothesis formulation and testing will be required in a number of areas. We believe there is an intrinsic relationship between the instrumental and communicative forms of management for each of the reasoning strategies. So I guess I have got that sort of internal list, and I work out what hasn't been covered at the end. Danielle, aware of the time and the day's other commitments, nevertheless, precipitated what was to follow with a simple question: Danielle: Is there anything we haven't covered that you think we really need to? Neve's purpose in telling this story had been to encourage M to reflect less on the “outcome” of her stressors and more toward her own responses to these stressors as possible factors contributing to her headaches. J's husband, Bob, is in attendance. The second wave of data collection consisted of written material from each of the 6 physical therapists. Grounded theory is a field-based research technique that seeks to generate theory.46 Although there is a debate among proponents of grounded theory concerning the level of preconceived theory with which a researcher enters the field, there is general support for the idea that theory that is generated from the data should be compared with or contrasted to existing theories (if they exist).46–48 An important feature of grounded theory, therefore, is the iterative relationship among data collection, data analysis, and review of the literature. A model of clinical reasoning in physical therapy characterized by the notion of “clinical reasoning strategies” is proposed by the authors. Synthesizing refers to the process of data reduction—a merging of stories, experiences, or cases to describe a typical pattern of behavior or response. Thomas-Edding Ethical reasoning includes the apprehension of ethical and practical dilemmas that impinge on both the conduct of intervention and its desired goals, and the resultant action toward their resolution. I'm not very good at sitting with someone with a form and saying “tick,” “tick,” “tick” down the form. The fi rst monograph describes the multifaceted process of clinical reasoning and utilization of evidence-based practice physical therapy management. Also within the folder was a notepad to write down field notes about nonverbal interactions, techniques, positions, or actions that the therapist (and the patient or caregiver) were engaged in and that would not have been obvious from listening to the audiotape itself. A few minutes into the physical examination, T, himself, provides a cue that Michael immediately follows up: “When I take a deep breath, my pain is eased for a minute.” Michael asks T to demonstrate this, observes the action, and, in response, teaches him how to enhance the effect by contracting the transversus abdominis muscle. MB Dr. This interplay is summarized in Figure 4. This has occurred, in part, because of the skills expected of physical therapists and development of the profession in a changing health care climate that requires increasing accountability in decision making as part of the process of providing desirable outcomes.1 Another reason for the rising importance of clinical reasoning is that independent and responsible decision making is now regarded as one of the characteristics of an autonomous profession.2,3 In addition to these reasons to justify the importance of clinical reasoning, clinical reasoning is relevant because every physical therapist has to make a wide variety of decisions in his or her daily clinical practice. Through management issues through ethical decision making behind the determination and carrying out of treatment sessions were observed in settings... Considered in relation to the telephone call, she had been working on tightness in N 's foot illustrates... 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