Clinical Decision Making and Therapists’

JHT READ FOR CREDIT ARTICLE # 097

Clinical Decision Making and Therapists’Autonomy in the Context of Flexor

Tendon Rehabilitation

Gail N. Groth, MHS, OTR/L, CHTUniversity of Wisconsin-Madison, Department ofKinesiology, Watertown, Wisconsin 53098

ABSTRACT: Sound clinical decision making (CDM) is one criticalfactor in the delivery of quality health care. The purpose of thiscross-sectional study was to examine therapists’ autonomy inCDM, to describe therapists’ clinical reasons influencing CDM,and to describe the influence of autonomy on actual clinical prac-tice. A survey was distributed to 754 hand therapists and descrip-tive statistics was performed. Of the 754 surveys, 191 werereturned (response rate 25.3%). Autonomy in CDM was perceivedto be low by most therapists. Greatest autonomy was seen in settingthe frequency of rehabilitation sessions, and the least autonomy inchoosing the protocol and the timing of initiation of rehabilitation.Shared decision making between therapist and surgeon occurredfrequently, however, CDM was rarely fully collaborative. Clinicalreasoning strategies were consistent with a novice-type approach.The perceived lack of autonomy in CDM negatively impacted ther-apists’ compliance with surgeons’ preferences.

J HAND THER. 2008;21:254–60.

Successful rehabilitation of flexor tendon (FT)injuries is a complex process that requires numerousclinical decisions by the occupational or physicaltherapist over a 12e to 16-week period. Complexityof the injury in combination with a fragile surgicalrepair makes sound clinical decision making (CDM) acritical factor in the delivery of quality rehabilitation.Examples of difficult FT clinical decisions that handtherapists may face include how to optimally posi-tion the digits and wrist in what type of postoperativesplint, when and how to deviate from a standardprotocol in response to unusual patient characteris-tics, and how to communicate clinical interventionpreferences to the referring surgeons, particularlyunder the conditions of geographical distance.

Sound CDM regarding rehabilitative treatmentinterventions is one critical component in the

delivery of quality health care. CDM is defined asthe point of clinical choice or judgment between alter-natives1 and occurs when one course of action is se-lected and chosen over all other options, even if thecourse of action includes doing nothing.2 Clinicalreasoning is defined as the cognitive processes andstrategies used to arrive at clinical decisions.3

Many team members contribute to the CDM pro-cess within FT rehabilitation. Of particular interest inthis study are the interactions and relative contribu-tions of the referring surgeons and treating handtherapists to the clinical decisions in FTrehabilitation.In many cases, surgeons and therapists work inproximity with frequent communication; in othercases, therapists work in separate clinics with signif-icantly less communication. In either case, the sameclinical decisions regarding progression of rehabili-tation must be made in a timely manner. Therapists’autonomy in CDM is therefore an importantconsideration in the delivery of quality health care.

Autonomy in CDM is one of the key traits of aprofession and implies a defined scope of practice, adistinct knowledge base, and expertise in a domain.4

For the purposes of this paper, autonomy is definedas a therapists’ freedom to use judgment and clinicalreasoning skills to make clinical decisions regardingpatients’ rehabilitation needs. Current practice inthe United States stipulates that hand rehabilitation

CLINICAL/ORIGINAL PAPER

This study was supported in part by the American Hand TherapyFoundation Burkhalter Grant 2002. A portion of the study data waspresented at the Annual Meeting of American Society of HandTherapists, Hollywood, California, 2003.

Correspondence and reprint requests to Gail N. Groth, MHS, OTR/L, CHT, University of Wisconsin-Madison, Department ofKinesiology, 1406 Beacon Drive, Watertown, WI 53098. e-mail:<[email protected]>.

0894-1130/$ e see front matter � 2008 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.

doi:10.1197/j.jht.2007.10.022

254 JOURNAL OF HAND THERAPY

mailto:[email protected]

is physician-prescribed and is, in this sense, not fullyautonomous. However, hand therapists do operateunder a defined scope of practice with a distinctknowledge base5 and expertise.6 Furthermore, mostreferrals to hand therapists include at least an ele-ment of ‘‘eval and tx,’’ with the expectation that ther-apists make autonomous clinical decisions regardingoptimal rehabilitation interventions.

Expectations for shared versus autonomous CDMin FT rehabilitation may vary among and betweentherapists and surgeons. If shared CDM is the expec-tation, then communication between therapist andsurgeon must occur frequently, despite organiza-tional or clinical barriers. If autonomous CDM isthe expectation (or the reality of geography), then thetherapist must possess and be able to critically applyan expert knowledge base that permits sound CDM.Negative consequences of low therapist autonomy inCDM include delayed progression of treatment, lackof attention to the individual’s illness experience, andinadequate tailoring of complex exercise regimens.Each of these consequences is capable of prohibitingthe restoration of finger range of motion, reengage-ment in activities of daily living, and thereforeparticipation in life roles.

The purpose of this cross-sectional study within thecontext of FTrehabilitation was to examine therapists’autonomy in CDM, to describe therapists’ clinicalreasons influencing CDM, and finally, to describe theinfluence of autonomy on actual clinical practice.

METHODS

A 52-item questionnaire was developed by theauthor to describe current clinical practices for reha-bilitation of FT injuries. Specifics of questionnairedevelopment, content, and distribution were previ-ously reported.7 The questionnaire was disseminatedto a convenience sample of 754 occupational andphysical therapists attending one of three continuingeducation courses in the Midwest region of theUnited States in 2002. Six items queried therapists’autonomy in CDM regarding progression of specificFT rehabilitation interventions with three responseoptions (MD Only, assigned value of zero; MD/thera-pist, assigned value of one; and Therapist only, assignedvalue of two):

This (these) professional(s) choose the post-operative protocol my

patient(s) follow:

This (these) professional(s)decide when therapy should be initiated:

on the frequency of scheduled therapy visits:

when to initiate active ROM exercises for my patients:when to discontinue protective splinting for my patients:

when to initiate resistive exercises for my patients:

Three items queried therapists’ clinical reasons influencing their CDM

and included:

The reason(s) active ROM is initiated in the typical

patient:The reason(s) protective splinting is discharged in the

typical patient:

The reason(s) resistive exercise is initiated in the typical

patient:Response options (circle as many responses as necessary): number of days

post-op, MD order, ROM measurements, suture technique, established

protocol, compliance issues, other [explain].

Data Analysis

An Autonomy Scale was created with values rangingfrom zero to 12 (higher values indicate higher thera-pist autonomy) based on the values assigned tothe three response categories (zero, one, or two).Responses indicating no autonomy (MD only) receivedzero points, a medium level (both) received one point,and a high level of therapist autonomy (therapistonly) received two points. An Autonomy Ratio was de-rived by dividing the Autonomy Scale score by 12, themaximum score possible. Values range from zero toone with higher values indicating higher therapist au-tonomy. A Collaboration Scale was also created. Thiswas a dichotomous (Yes/No) variable with ‘‘Yes’’ in-dicating therapists responded MD/Therapist to all sixitems and ‘‘No’’ indicating that some other responseswere provided. In all cases, therapists who did notprovide responses to all six items were excludedfrom the analyses. Descriptive statistics were per-formed on therapists’ demographics. An independentresearch-consulting agency performed all data entry(coding and cleaning) and data analyses using SPSS11.5 (SPSS Inc., Chicago, IL) for Windows.

RESULTS

One hundred and ninety-one questionnaires werecompleted (response rate of 25.3%). Therapists’ cre-dentials, experience, and practice settings were de-scribed in a previous study7 and a brief summaryfollows (Table 1). Nearly half (41%) of the respondentswere Certified Hand Therapists (CHTs) with an evenly

TABLE 1. Characteristics of surveyed therapists (n¼ 191)

Disciplines of surveyed therapists (n¼ 191)CHT (OT) 62 (32.5%)CHT (PT) and/or PT 33 (17.3%)OT 62 (32.5%)

Number of years experience in hand specialty (n¼ 178),5 71 (39.9%)5e9 50 (28.1%)10e14 37 (20.8%)$15 20 (11.2%)

Primary practice setting (n¼ 191)Hospital-based 69 (36.9%)Corporate-owned 55 (29.4%)Therapist-owned 34 (18.2%)Physician-owned 22 (11.8%)Other 7 (3.7%)

JulyeSeptember 2008 255

distributed range of years of specialized hand experi-ence. Sixty percent of therapists reported having fiveor more years of hand therapy experience, and there-fore were considered expert hand therapists.6

Practice settings of the therapists included hospital-based, corporate-owned, therapist-owned, physician-owned practices, and other practice settings. Mosttherapists (61.7%) rehabilitated between one andnine FT patients during the past year (range¼ 0e15).

Therapists’ Autonomy in CDM

Therapists’ autonomy for specific clinical decisionsvaried throughout the progression of FT rehabilitation(Table 2). Therapists reported experiencing the high-est degree of autonomy in the determination of thefrequency of therapy sessions (therapist only¼ 24.8%)and the lowest autonomy for the choice of protocol(therapist only¼ 1.8%) and initiation of therapy(therapist only¼ 1.2%). Overall, referring surgeonsgenerally have more autonomy regarding the keyelements of rehabilitation than do therapists.

The mean Autonomy Scale score was 5.16 (n¼ 165,r¼ 1e12) indicating that CDM most frequently clus-tered at the midpoint of the scale and was sharedbetween therapist and surgeon. The AutonomyRatio was 0.43 (n¼ 165), indicating that therapistsperceived a reliance on the surgeon in coordinatingrehabilitation. Collaboration (shared decision makingbetween therapist and surgeon in all six items)occurred in 13.8% of the cases.

Clinical Reasoning

Following an established protocol, counting thenumber of days post-op, and following the MD orderwere the three clinical reasons most frequentlyreported (range¼ 55e70%) by therapists for initiat-ing all three items (active ROM, discharging protec-tive splint, and initiating resistive exercise) (Table3). The clinical reasons least used during CDM wereROM measurements, compliance issues, and suturetechniques (range¼ 19e38%).

Influence of Therapists’ Autonomy on ActualClinical Practice

Actual clinical practice varied from therapists’preferences in two key elements: initiation of therapy

TABLE 2. Autonomous Clinical Decision Makingin Specific Components of Flexor Tendon

Rehabilitation (n¼ 191)

Key Element MD (%) Both (%) Therapist (%)

Protocol 17.6 80.6 1.8Initiation 66.1 30.3 1.2Frequency 6.7 70.3 24.8AROM 15.2 77.0 8.5D/C protective splint 17.0 73.3 9.1Resistance 13.9 70.9 13.9


and initiation of active ROM exercises. Therapistsreported preferences for earlier initiation of therapyand earlier initiation of active ROM exercises thanwhat occurred in actual practice (therapy, p¼ 0.00,active ROM, p¼ 0.00). It is presumed that if thera-pists initiated rehabilitation and active ROM exer-cises later than they prefer, it is in concordance withthe surgeons’ preferences. This finding is consistentwith the low level of autonomy reported for initiatingtherapy (1.2%) and initiating active ROM (8.5%),however, is somewhat surprising considering mosttherapists (77%) reported shared decision making inthe initiation of active ROM. No significant differ-ences were noted between actual and preferredpractice regarding initiating resistive exercise, dis-continuing protective splint, or frequency of visits.

Twenty-five percent of all therapists reportedagreed or strongly agreed to occasionally prescribingtherapy the referring surgeon might disagree with.This percentage varied when cross-tabulated withyears of experience (Fig. 1). Forty percent of thera-pists with 10e14 years of specialty experience per-ceive that their prescriptions may vary from thesurgeon’s preferences. It is unknown if the smallerpercentage (27.8%) for therapists with 15 or moreyears of experience is indicative of greater compli-ance with surgeon’s preferences, or simply fewertherapists in that category within this study. Sixty-three percent of therapists with less than five yearsexperience disagreed or strongly disagreed with thestatement. It is to be noted that this question referredglobally to FT rehabilitation and not any specificintervention or component of rehabilitation.

DISCUSSION

This study examined therapists’ autonomy in sixspecific clinical decisions and found that autono-mous CDM occurs infrequently for both therapistsand surgeons in the context of FT rehabilitation. Thetypes of clinical decisions examined included anintervention decision (choosing of protocol), several

TABLE 3. Comparative Reasoning between the Initiationof Three Key Elements (n¼ 191)

Initiationof Active

ROM

DischargeProtective

Splint

Initiationof

Resistance

Novice clinical reasoningEstablished protocol 1: 63.6% 1: 61.9% 1: 70.3%Number of days post-op 2: 62.4% 2: 58.5% 2: 58.8%MD order 3: 57.0% 3: 55.2% 3: 55.2%

Advanced clinical reasoningSuture technique 4: 38.2% 6: 22.4% 5: 24.8%Compliance issues 5: 27.3% 4: 33.9% 6: 24.2%ROM measurements 6: 19.4% 5: 30.3% 4: 38.2%Other 7: 5.5% 7: 4.8% 7: 8.5%

Therapists were instructed to circle all applicable choices, there-fore the totals are not 100%.

timing decisions (initiation of rehabilitation, activeROM exercises, discharge of protective splint, andinitiation of resistive exercises), and a service deliv-ery management decision (frequency of therapyvisits). The low response rate from this conveniencesample requires that caution be exercised in theinterpretation of the data.

Therapists Lack of Autonomy in CDM

Shared decision making between therapists andsurgeons occurred far more frequently than autono-mous CDM in all but one of the six clinical decisions(initiation of rehabilitation). However, full collabora-tion defined within this study as shared decisionmaking for all six decisions did not occur often (13.8%of the time). This low percentage demonstrates thatwhile shared decision making occurs frequently,many decisions in the context of FT rehabilitationare not fully collaborative. Instead, clinical rehabili-tation decisions tend to be made by the surgeon.

The issue of establishing an optimal level of ther-apists’ autonomy in CDM to achieve the best patientoutcome clearly needs to be addressed. Perhaps,neither high levels of autonomy by the surgeon norby the therapist are optimal but full collaborationwould be the most desirable goal. Within this study,however, we did see therapists who sought fullautonomy in CDM whereas others abdicated andsought only to follow surgeon orders. It appears,therefore, that optimal autonomy is dependent onboth the individuals providing therapy and the site ofcare delivery.

Autonomous decision making should be examinedunder the paradigm of evidence-based practice (EBP).In this paradigm, few clinical decisions made byhealth professionals are autonomous. This is becauseEBP is defined as the integration of best researchevidence with clinical expertise and patient pre-ferences.8 The implication is that clinical decisionsdo not solely belong with the therapist, but rest in

21.217.4

40

27.8

0

5

10

15

20

25

30

35

40

45

<5 5to 9 10 to 14 15 or moreYears of Hand Specialty Experience

Percen

t

FIGURE 1. ‘‘I occasionally prescribe therapy that the re-ferring surgeon might disagree with’’: Cross-Tabulationof Years of Hand Specialty and ‘Agree’ (n¼ 38).

a shared state between patient and therapist.Similarly, a therapist integrates evidence receivedfrom the surgeon along with patient preferences toarrive at the optimal clinical decision. In neither casedoes the therapist make autonomous clinical decisions.

Clinical Reasoning Strategies

Another interesting issue arising from this study isthe frequent utilization of clinical reasoning strate-gies that are characteristic of novice reasoning (Table3).9,10 The most commonly reported clinical reason-ing strategy of using established protocols to make clin-ical decisions (such as the Modified Kleinert11 orDuran12 protocols) has been suggested by other stud-ies outside the context of FTrehabilitation to suppressclinical reasoning when the protocols are used non-discriminately.9 Nondiscriminate use of clinical pro-tocols occurs when individualized care is notprovided. The second most commonly reported rea-soning strategy of the number of days post-op is an ex-tension of the first as most FT protocols are describedchronologically and again, little clinical reasoning isexhibited. Finally, the third most commonly reportedstrategy of following MD orders does not require or en-hance clinical reasoning. An alternative explanationfor the predominance of these clinical reasoning strat-egies is that the therapists were asked to respondaccording to a typical or routine patient. Perhaps anatypical scenario would stimulate deeper or moreadvanced clinical reasoning.

Conversely, advanced clinical reasoning strategieswere infrequently reported. These included knowl-edge of suture technique, compliance issues, and ROMmeasurements. The first two of these strategies are con-sidered advanced because they require knowledge ofthe surgical procedure and of the psychosocial attri-butes of individuals, and the implications of the ap-plication of this knowledge on rehabilitation. UsingROM measurements to assist in CDM demonstratesadvanced clinical reasoning because this strategydemonstrates an understanding of the implicationof tendon adhesions on finger ROM. For example,the pyramid program is a method of exercise pre-scription in FT rehabilitation that is based on ROMmeasurements.13

CDM Frameworks

Developing an understanding of autonomy inCDM is enhanced by examining theoretical frame-works of CDM.14 Many CDM frameworks originatedin medicine and have found extensive support innursing literature.15 There is a growing body of reha-bilitation literature that examines these frameworks.16

The literature on CDM may be summarized by twodifferent and seemingly opposing frameworks: ana-lytic and intuitive.15 A third framework (Cognitive


Continuum Model) proposes that therapists may usea combination of these two frameworks that dependson the nature of the particular clinical decision.17,18

The analytic framework15 describes a systematicand conscious process where therapists use a varietyof cues (i.e., zone of injury, suture technique, range ofmotion, and previous experience) to weigh opposingoptions for a clinical decision.3,19e24 The intuitiveframework describes CDM as occurring at a moresubconscious level25 and the therapist, rather thanthe cues, serves as the primary decisional force.26

Therapist expertise plays a significant role in theuse of intuition27 with experts using a more intuitiveframework28 and novices using a more analyticframework. The most frequently used clinical reason-ing strategies in our study support an analytic frame-work (Table 3).

Other Factors that Influence CDM

Our study describes a single factor—autonomy—inseveral specific clinical decisions in the context of FTrehabilitation, however, many other factors arethought to influence CDM in rehabilitation and areworthy of future study. These include, but are notlimited to, different types of decisions,29,30 level ofexpertise,22,28 complexity of the clinical decision,31

types of reasoning used, the effect of time constraintsin CDM, economic factors from the health organiza-tion or the insurance companies, shared decisionmaking between patients and therapists, and avail-ability of research evidence for CDM. For one specificexample, level of expertise (either years of experienceor familiarity with FT rehab) is likely to influence theclinical reasoning process underlying the decisions,however, this factor was not analyzed in this study.In a second example, further characterization of therelationships between surgeons’ trust and therapists’autonomy on the dependent variable of CDM is alsolikely to impact the results.

Several limitations impact the findings of this study.Self-reports and retrospective recall have beenshown to differ from observations of actual CDM.32

Qualitative methods such as nonparticipant observa-tion, in-depth interviews, or think-aloud protocolswould provide deeper insight into therapists’ clinicalreasoning than the quantitative method used. Becauseof the quantitative methodology used in conjunctionwith a low response rate, it is unknown if the availabledata are representative of the population of handtherapists. Responses may be different if the samesurvey was distributed to a random sample or if alarger response rate was achieved. Furthermore, thedata were collected in 2002 and it is unknown if ther-apists’ autonomy and physicianetherapy relationshave systematically changed in that time. The lowresponse rate indicates the need for additional studyto reexamine these same issues addressing the


methodological shortcomings. However, this paperrepresents the first empirical study examining CDMin a population of hand therapists, and the methodol-ogy serves to generate hypotheses for future studies.

CONCLUSION

Therapists’ autonomy within the context of sixspecific FT rehabilitation decisions was perceived tobe low by most respondents. The greatest autonomywas reported in setting the frequency of rehabilita-tion sessions and the least autonomy in choosing theprotocol and the timing of initiation of rehabilitation.Clinical reasoning strategies used in CDM wereindicative of novice reasoning, however, this maybe a result of the methods used in this study. Shareddecision making between therapists and surgeonsoccurred frequently, however, full collaboration wasunusual. The perceived lack of autonomy in CDMnegatively impacted therapists’ compliance withsurgeons’ preferences.

Acknowledgments

The author thanks all the therapists who were generouswith their time and expertise in filling out the survey. Shealso thanks the course coordinators who facilitated thedistribution of the surveys (Nancy Cannon, Barb Haines,and Rebecca von der Heyde) and the American HandTherapy Foundation for funding assistance.

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JHT Read for CreditQuiz: Article # 097

Record your answers on the Return Answer Formfound on the tear-out coupon at the back of this is-sue. There is only one best answer for eachquestion.

#1. Shared CDM between therapist & surgeon wasfound to bea. most often fully collaborativeb. rarely fully collaborativec. almost never collaboratived. unimportant to therapists answering the

survey#2. The highest rate of autonomy in CDM by the ther-

apists was found in decidinga. when to initiate active motionb. when to initiate resistive exercisec. when to initiate PIP flexion contracture

splintingd. the frequency of clinical visits

#3 Of the respondents to the survey approximatelywhat percentage were CHTs

a. 80b. 60c. 40d. 20

#4. The rate of response to the survey requires thereader of this study toa. accept the Null Hypothesisb. reject the Null Hypothesisc. be cautious when interpreting the datad. be sophisticated in the understanding of

statistics#5. While this study was limited to considerations

about CDM with flexor tendon management,the data can clearly be applied to most otherhand therapy situationsa. falseb. true

When submitting to the HTCC for re-certification,please batch your JHT RFC certificates in groupsof 3 or more to get full credit.


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Clinical Decision Making and Therapists’