clinical strategies in physical therapy

7/22/2019 clinical strategies in physical therapy

1/19

Clinical Reasoning Strategies in

Physical Therapy

Background and Purpose.Clinical reasoning remains a relatively under-researched subject in physical therapy. The purpose of this qualitative

study was to examine the clinical reasoning of expert physical thera-

pists in 3 different fields of physical therapy: orthopedic (manual)

physical therapy, neurological physical therapy, and domiciliary care(home health) physical therapy.Subjects. The subjects were 6 peer-designated expert physical therapists (2 from each field) nominated by

leaders within the Australian Physiotherapy Association and 6 other

interviewed experts representing each of the same 3 fields.Methods.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. Results. A model of clinical reasoning in physical therapycharacterized by the notion of clinical reasoning strategies is pro-

posed by the authors. Within these clinical reasoning strategies, the

application of different paradigms of knowledge and their interplay

within reasoning is termed dialectical reasoning. Discussion andConclusion. The findings of this study provide a potential clinicalreasoning framework for the adoption of emerging models of impair-

ment and disability in physical therapy. [Edwards I, Jones M, Carr J,

et al. Clinical reasoning strategies in physical therapy. Phys Ther.

2004;84:312335.]

Key Words: Clinical practice, Clinical reasoning strategies, Decision making, Dialectical reasoning,

Knowledge.

Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer, Gail M Jensen

312 Physical Therapy . Volume 84 . Number 4 . April 2004

Resea

rchReport


2/19

Clinical reasoning refers to the thinking anddecision-making processes that are used in clin-ical practice. Higgs and Jones1 have definedclinical reasoning as a process in which the

therapist, interacting with the patient and others (suchas family members or others providing care), helpspatients structure meaning, goals, and health manage-ment strategies based on clinical data, patient choices,and professional judgment and knowledge. Over the lastdecade, clinical reasoning has come to prominence as asubject for study. This has occurred, in part, because ofthe skills expected of physical therapists and develop-ment of the profession in a changing health care climatethat requires increasing accountability in decision mak-ing as part of the process of providing desirable out-comes.1 Another reason for the rising importance ofclinical reasoning is that independent and responsible

decision making is now regarded as one of the charac-teristics of an autonomous profession.2,3 In addition to

these reasons to justify the importance of clinical reason-ing, clinical reasoning is relevant because every physicaltherapist has to make a wide variety of decisions in his orher daily clinical practice. All clinicians, therefore, havean interest in improving their decision making. Reflect-ing on decision making is part of a sound clinicalreasoning process and is an important source of learningin practice.1

The Development of Clinical Reasoning inPhysical TherapyEarly studies and models of clinical reasoning in physicaltherapy provided explanations of clinical reasoning thatwere similar to those of physicians and were mainlyconcerned with diagnosis.49 The common factor wassupport of the hypothetico-deductive model of reason-ing. The hypothetico-deductive model remains the most

enduring clinical reasoning model in medicine and wasderived from a cognitive science perspective.10 In the

I Edwards, PhD, Grad Dip Physio (Ortho), MAPA, is Physiotherapist, The Brian Burdekin Clinic, Adelaide, South Australia, Australia, and Lecturer,

School of Health Sciences, University of South Australia. Address all correspondence to Dr Edwards at School of Health Sciences, University of

South Australia, North Terrace, Adelaide, South Australia, Australia 5000 ([email protected]).

M Jones, MAppSc (Manip Ther), Cert Phys Ther, Grad Dip Advan Manip Ther, MMPA, MAPA, is Senior Lecturer and Director, Graduate Programs

in Musculoskeletal and Sports Physiotherapy, School of Health Sciences, University of South Australia.

J Carr, Dip Physio, Grad Dip F Ed, is Physiotherapist, Murray Mallee Community Health Service, Murray Bridge, South Australia, Australia.

A Braunack-Mayer, PhD, is Lecturer in Ethics, Department of Public Health, University of Adelaide.

GM Jensen, PT, PhD, FAPTA, is Professor of Physical Therapy, Associate Dean for Faculty Development and Assessment, and Faculty Associate,

Center for Health Policy and Ethics, School of Pharmacy and Allied Health, Creighton University, Omaha, Neb.

All authors provided concept/idea/research design. Dr Edwards, Mr Jones, and Dr Braunack-Mayer provided writing and project management.

Dr Edwards provided data collection, and Dr Edwards, Mr Jones, and Ms Carr provided data analysis. Dr Edwards provided fund procurement. The

authors thank Dr Marie Williams, Associate Professor, School of Health Sciences, University of South Australia, for her helpful comments in

reviewing the manuscript.

This study was approved by the Human Research Ethics Committee of the University of South Australia and supported by a grant from the South

Australian branch of the Australian Physiotherapy Association.

This article was received September 20, 2002, and was accepted October 17, 2003.

Physical Therapy . Volume 84 . Number 4 . April 2004 Edwards et al . 313


3/19

hypothetico-deductive method, the clinicians attend toinitial cues (information) from or about the patient.From these cues, tentative hypotheses are generated.This generation of hypotheses is followed by ongoinganalysis of patient information in which further data arecollected and interpreted. Continued hypothesis cre-ation and evaluation take place as examination and

management are continued and the various hypothesesare confirmed or negated.

The hypothetico-deductive reasoning model, althoughderived from cognitive science, has its roots in theempirico-analytical research paradigm.11 The empirico-analytical research paradigm, which is also known as thescientific or positivist paradigm, holds that truth orreality (ie, knowledge) is objective and measurable,thereby utilizing observation and experiment to producea result that, in turn, can be generalized and also leads toprediction. For example, randomized controlled trialsare carried out within this paradigm of research. Inclinical practice in physical therapy (as in medicine),hypothetico-deductive reasoning aims, within the limita-tions of available standards, to validate information ordata acquired from the patient through measurement ina reliable fashion.

Other models of clinical reasoning from this samecognitive science (empirico-analytical) perspective havefocused less on the processes and more on the organi-zation and accessibility of knowledge stored in theclinicians memory. Examples of knowledge organiza-tion used in clinical reasoning include illness scripts11

and pattern recognition.12,13 In making use of illnessscripts or pattern recognition, the clinician recognizescertain features of a case almost instantly, and thisrecognition leads to the use of other relevant informa-tion, including if-then rules of production, in theclinicians stored knowledge network.14 This form ofreasoning moves from a set of specific observationstoward a generalization and is known as forward rea-soning.12 Forward reasoning contrasts with hypothetico-deductive reasoning where a person moves from ageneralization (multiple hypotheses) toward a specificconclusion.14 Experts generally agree that both forms of

this cognitively oriented reasoning are used at differenttimes.10,15 Pattern recognition is faster and more effi-cient and is used by expert and experienced practitio-ners in their domain.14 Hypothetico-deductive reasoningis used by more inexperienced practitioners and byexperts when faced with an unfamiliar problem or amore complex presentation.10,15 These 2 cognitivelyoriented methods taken together are often referred to asdiagnostic reasoning.4,5,16,17

Clinical Reasoning Research Using AlternativeMethods to Cognitive ScienceUntil the mid-1990s, the forms of clinical reasoningdiscussed were the main forms of reasoning described inthe physical therapy literature. Researchers of expertiseand clinical reasoning in physical therapy,1820 nurs-ing,2126 and occupational therapy2731 then began to

consider alternative methods for studying the develop-ment of expertise and the nature of clinical reasoning.In each field, engagement with the patient and family, ascompared with the emphasis on the initial diagnosis, inour opinion, led clinicians to ask different kinds ofquestions regarding the nature of patients experiencesof pain, illness, and disability. That is, many of theclinical tasks in these health care professions required anunderstanding of the person as well as the disease.25,27

This understanding raises a worldfor the patient thathas both biomedical and lived experience. This polarityhas been described in the medical, adult learning, andsociological literature.3236

Most of the clinical reasoning research carried out up tothis point had been in the laboratory rather than at theactual site of practice.37 Researching clinical practicefrom the site of clinical practice, by including theperspectives of clinicians and patients, would require aparadigm of research that could include many variablesover most of which the researcher would have littlecontrol.38,39 In contrast to the empirico-analyticalresearch paradigm, an interpretive research approachrecognizes that truth or knowledge is related to meaningand the context in which it is produced and, therefore,

concedes that in any given situation there may bemultiple realities, truths, or perspectives.11

The explanations of clinical reasoning emanating fromthis collective research in the interpretive paradigm inthe health care professions are said, by their variousproponents, to stand in contrast to hypothetico-deductive or diagnostic reasoning. One such example isnarrative reasoning.27 Narrative reasoning seeks tounderstand the unique lived experience of patientsareasoning activity that could be termed the construc-tion of meaning. In patients (or therapists for that

matter) telling of stories or narratives, there is a choicein which some elements are expressed, some elementsare emphasized over others, and still other elements maynot find expression.40 For example, the particular tell-ing of a story or history by patients represents theirinterpretation of events over time. Such interpretations(albeit not necessarily consciously constructed) may notbe neutral in their effects on the teller.40,41 In thecontext of clinical practice in physical therapy, narrativereasoning concerns the understanding of patients sto-ries in order to gain insight into their experiences ofdisability or pain and their subsequent beliefs, feelings,

314 . Edwards et al Physical Therapy . Volume 84 . Number 4 . April 2004


4/19

and health behaviors.27,40 This includes the patientsability to make choices and learn new perspectives.35

Patients narratives, therefore, may provide insights forintervention and its outcomes.41 Narrative reasoning isdistinguished from hypothetico-deductive reasoning inthat hypotheses concerning patients interpretationsof their experiences are not validated by testing but by

consensus between therapists and patients.27

Influenced by the critical social theory of the Germanphilosopher Habermas,33 Mezirow35 distinguishedbetween different forms of learning: instrumental learn-ing and action, and communicative learning and action.Instrumental learning and action (like hypothetico-deductive reasoning) has as its purpose the determina-tion of cause-effect relationships, which lead to predic-tions about observable events that are either correct orincorrect. The aim ofcommunicativelearning and action,however, is not to establish cause-effect relationships butto increase insight and a common understanding of asituation through a mutual learning process between thetherapist and the patient.

In communicative learning and action, the learner(either therapist or patient) when confronted by anunfamiliar experience or dilemma (eg, in a patientscase, ongoing pain, disability) becomes aware throughcritical reflection of the underlying assumptions or per-spectives that he or she holds about particular situations(eg, past experience and beliefs concerning injury orphysical therapy intervention).35 The capacity to firstunderstand the perspectives a person currently holds,

then reflect on the adequacy of these perspectives, andfinally adopt newer, more constructive or reliable per-spectives is calledtransformatory learning.35

The Scope of Early Studies in ClinicalReasoning in Physical TherapyNot only were the early studies of clinical reasoning inphysical therapy more concerned with the diagnosticprocess, the majority of these studies were carried out inorthopedic settings.4,5,18,4145 Physical therapist practice,however, occurs across a wide spectrum of health careand, as a profession, requires solving complex and

poorly defined practice problems.36

In an Australiansetting alone, a person could consider the range of skillsneeded, to do rehabilitation among aboriginal people inremote areas, cardiothoracic physical therapy in anacute hospital, orthopedic (manual) physical therapy ina private practice, physical therapy for children withorthopedic problems, or physical therapy aimed at help-ing retrain motor skills in adults following a stroke. Thebreadth and variation in the skills required, as thedemands of each area are considered, is vast.

Besides technical skills, cultural, social, and personalknowledge and understanding together with diagnostic,teaching, negotiating, listening, and counseling skillsmight all play a greater or lesser role in the clinicalreasoning process. A different mix of clinical reasoningskills may be needed for therapists working in the samesettings according to their own particular interests,

beliefs, or clinical and life experiences. Perhaps thesame therapists use different combinations of clinicalreasoning skills at different times and occasions accord-ing to the particular patient or client and the context ofcare.

We believe there is a need, therefore, for identificationof the range of clinical reasoning skills or strategiesbeing utilized by experts in different aspects of physicaltherapy care. This process of identification, we contend,is important as the profession considers the variety andscope of its activities and seeks to answer questions suchas,How will physical therapy define itself and its role(s)in the community in an increasingly competitive healthcare market?and How can future practitioners be besteducated and prepared to function in the various fieldsof health care in which physical therapists practice?

The aim of our study was to examine the nature andscope of clinical reasoning and knowledge used byexpert clinicians in 3 different fields of physical therapy:orthopedic (manual) physical therapy, neurologicalphysical therapy, and domiciliary care (or home health)physical therapy. Our objective was to generate furthertheory concerning clinical reasoning in physical therapy.

We also sought to develop a new model to explain theclinical reasoning already in use among physical thera-pist clinicians. Due to the large body of data generatedby our study, we will concentrate on reporting thefindings in terms of the nature, scope, and manifestationof the clinical reasoning skills of the therapists. We willrefer only briefly as to how the knowledge for these skillsis acquired.

Method

Design

The research approach we used follows that of Jensenet al.18 Using a grounded theory, case study approachwithin an interpretive research paradigm (explained inthe Method section), Jensen and colleagues were thefirst researchers to systematically study the clinical workof physical therapists in order to differentiate novicepractitioners from their expert counterparts. One oftheir early explanations (or conceptual frameworks) ofthe differences among orthopedic physical therapists inoutpatient settings was that expert clinicians exhibitedclinical qualities that differed from those of their novicecounterparts. Jensen et al identified the following as



5/19

attribute dimensions that distinguish between masterand novice clinicians: (1) ability to control the treatmentenvironment, (2) wide use of patient illness and diseasedata in a context-rich evaluation, (3) focused verbal and

nonverbal connection with the patient, (4) equal impor-tance of teaching to hands-on care, and (5) confidencein predicting patient outcomes.

The grounded theory approach and case study work areboth methods that seek to understand human behaviorwithin a natural context and from the participantspointof view.38,39,46 The phenomenon studied is clinical deci-sion making, and the context is the clinical practice inwhich this decision making takes place. Each of the 6physical therapists in the primary sample, together withtheir clinical practices, constitutes a case for study.

Grounded theory is a field-basedresearch technique that seeks to gener-ate theory.46Although there is a debateamong proponents of grounded theoryconcerning the level of preconceivedtheory with which a researcher entersthe field, there is general support for

the idea that theory that is generatedfrom the data should be compared withor contrasted to existing theories (ifthey exist).4648 An important featureof grounded theory, therefore, is theiterative relationship among data col-lection, data analysis, and review of theliterature. This iterative process meansthat the findings of the study are pro-gressive and represent the develop-ment of a series of conceptual frame-works (or interim explanations of thedata). Each conceptual framework isthe result of a continued refinement ofdata collection, data analysis, and refer-ence to existing theories in variousfields of relevant literature.

The 3 fields of orthopedic (manual)physical therapy, neurological physicaltherapy, and domiciliary care (homehealth) physical therapy were chosenfor our study because they representquite diverse areas of physical therapistpractice from which we could investi-

gate the formation of potentially differ-ent domains of knowledge and reason-ing skills. The determination of thesample size of 6 primary informants(2 clinicians from each field) rested onKluzels argument that, [t]he validity,meaningfulness and insights generatedfrom qualitative inquiry have more to

do with the information richness of the cases selectedand the observations/analytical capabilities of theresearch than the sample size.49

The research panel (consisting of an orthopedic physicaltherapist who was the primary researcher; 3 other phys-ical therapists with various expertise in qualitativeresearch, adult learning, and teaching; and one othermember, a lecturer in ethics) agreed that 6 cases wouldyield a large and sufficient amount of data. The 6physical therapists were selected by a purposive50 orcritical case sampling method.47

Australian Physiotherapy Association (APA) consultantsare prominent physical therapists appointed to act aspublic spokespeople for the profession on account of

Figure 1.Criteria of expertise.

Figure 2.Interview guide questions.



6/19

their current standing and expertise in their respectivefields. The APA consultants for each field were con-tacted and asked to nominate, based on criteria ofexpertise (Fig. 1), a short list of physical therapistsregarded by their peers as experts in their particularfields. Not all of the characteristics described in Figure 1,however, are operationally defined. The consultantswere asked to nominate only physical therapists whomthey felt possessed at least 5 of the 7 criteria. Twophysical therapists from each list were selected at ran-

dom, and all therapists agreed to participate in the study.An information sheet was sent to each therapist beforeconfirming his or her participation and signing consentforms. These 6 primary informants had clinical practice

experience ranging from 13 to 33 years (Tab. 1). Alltherapists had current or past teaching experience andeither held postgraduate qualifications or were engagedin formal postgraduate study.

In this article, the physical therapists are identified bypseudonyms, with the first letter of these pseudonymsalso being the first letter of the field in which they work(eg, Neve is a neurological therapist). None of thetherapists in this primary sample had formal training inclinical reasoning theory. Data collection commencedfollowing approval of the study by the Human ResearchEthics Committee of the University of South Australia.

Data CollectionData collection took place, in the manner of groundedtheory, in 3 waves over the course of approximately 1year. The first data collection consisted of observation oftreatment sessions and semistructured and unstructuredinterviews (see Fig. 2 for sample questions). Each phys-ical therapist wasshadowed51 over the course of 2 or 3days of their usual work. The orthopedic and neurolog-ical physical therapists were all observed in the rooms oftheir private practices. The domiciliary care (home

Table 1.Abridged Resumes of Participating Physical Therapistsa

Years SinceGraduation Work Setting Teaching Experience Qualifications

Denise* 14 Domiciliary care/senior PT Supervision of final-year students BAppSc, MAppSc candidate

Danielle* 13 Domiciliary care/senior PT Supervision of final-year students BAppSc Grad Dip

Health CounselingDianne 31 Community health center Supervision of final-year students Dip PT

Dorothy 30 Community health center Supervision of final-year students Dip PT

Neve* 33 Neurophysiotherapy/private practiceprincipal

Clinical tutorundergraduatecourse

Dip PT, Dip Psychosynthesis

Narelle* 12 Neurophysiotherapy/private practiceprincipal

Clinical tutorundergraduatecourse

BAppSc, MAppSc

Nancy 28 Associate professor Lecturing, research Dip PT, BA, PhD

Nicole 14 Senior lecturer Lecturing, research BAppSc, PhD

Michael* 22 Manipulative PT/principal privatepractice

Lecturerpostgraduate courses Dip PT, Grad Dip Manip Ther,MAppSc (physio)

Monica* 15 Manipulative PT/principal private

practice

Tutor postgraduate course in

manipulative therapy

BAppSc, Grad Dip Manip Ther

Meredith 16 Manipulative PT/principal privatepractice

Tutor postgraduate course inmanipulative therapy

BAppSc, Grad Dip Manip Ther

Marion 14 Manipulative PT/principal privatepractice

Tutor postgraduate course inmanipulative therapy

BAppSc, MAppSc, PhDcandidate

aAsterisk denotes participant in primary sample. PTphysical therapist.

Table 2.Observed Number of Treatments and Hours Spent With Each PhysicalTherapist

No. of

Treatments

Hours

Observed

Orthopedic (manual) therapistMichael

22 12

Orthopedic (manual) therapistMonica

19 15

Domiciliary care therapistDenise

6 14.5

Domiciliary care therapistDanielle

7 12

Neurological therapist Neve 12 13Neurological therapist Narelle 13 13

Total 79 79.5



7/19

health) physical therapists were observed during visits tothe homes of their patients.

The treatment sessions and interviews were audiotapedto enable the researcher to focus on the more subtleexchanges (such as nonverbal interaction) betweenphysical therapist and patient, while still permitting

detailed analysis of the overall dialogue on later occa-sions. A microcassette recorder with a very small omni-directional microphone was used. The cassette recorderwas attached by Velcro* to the inside of a folder. Alsowithin the folder was a notepad to write down field notesabout nonverbal interactions, techniques, positions, oractions that the therapist (and the patient or caregiver)were engaged in and that would not have been obviousfrom listening to the audiotape itself. Such observationswere recorded against the reading of the audiotapecounter. This meant that when listening to the audio-tapes later, there was a written commentary supplyingboth contextual information and a workable indextomaterial on the audiotapesan important factor forcoding and the later construction of case studies.Seventy-nine treatment sessions were observed across the3 fields (Tab. 2).

The second wave of data collection consisted of writtenmaterial from each of the 6 physical therapists. Thepurpose of this data collection was to identify potentialsources of knowledge (eg, mentors, clinical and lifeexperiences) that may have influenced the therapistsprofessional development in a manner expressed intheir clinical practices. The need for these data had been

identified by the research panel in the process of theinitial coding and data analysis about 4 months after thefirst data collection period and was based on a prelimi-nary identification of diverse sources of knowledge beingused in practice. At that time, the therapists were askedto write down on a timeline those factors and peoplewhom they considered important influences on theirprofessional lives. The therapists were told that this wasnot meant to be a curriculum vitae but rather a personalreflection on those influences, which could includepeople and events outside the profession.

The third wave of data collection took the form ofsemistructured interviews with 6 other physical thera-pists (2 therapists from each of the same 3 fields) 12months after the initial fieldwork. These therapists werea convenience sample50 of expert therapists who wereinvolved in teaching in one of the relevant 3 practiceareas through the University of South Australia. Thetherapists were asked the same sample questions regard-ing issues of practice as those that the therapists in theprimary sample were asked. Before this process started,

the 6 individual case studies had been written and sent tothe relevant therapist in the primary sample for corrob-oration. The aim of this third wave of data collectionwere to see whether data in the form of responses andthemes began to recur.52 The data from the secondsample were incorporated in the composite case studiesrepresenting each field to provide further commentary

or corroboration of the data from the primary sample.These data were clearly distinguished in the compositecase studies from the data of the primary sample andalso kept appropriately proportionate to the data fromthe primary sample. That is, data from this secondarysample were used to support data from the primarysample and not to provide the main evidence for themeidentification or development within the case studies.

Data AnalysisData analysis for a study such as ours can be consideredhaving 4 stages: coding, individual case studies, compos-ite case studies (cross-case analysis within settings), andcomparative analysis (cross-case analysis across settings).The data reduction and analysis for the study wasorganized around a set of cognitive processes identifiedby Morse53(p27): (1) comprehending, (2) synthesizing,(3) theorizing, and (4) recontextualizing.Comprehendingis the cognitive process in which the researcher in thefield gains both insight and sensitivity concerning boththe setting and the data. This process includes not onlydata collection but also the initial processes of coding.Synthesizing refers to the process of data reductionamerging of stories, experiences, or cases to describe atypical pattern of behavior or response. Theorizing is a

process whereby alternative explanations or models areconsidered. Recontextualizing refers to the process inwhich the emerging theory is considered in relation toother settings or groups. This process involves compar-ing findings with existing or established theory. In agrounded theory approach, these steps are repeatedseveral times with each subsequent analysis of data.39,46

A panel of 3 coders examined transcripts reflecting whatoccurred during treatments and interviews and codedthem for clinical reasoning strategies, knowledge frame-works, and sources of knowledge. Ascertaining inter-

coder agreement was based on the method of Miles andHuberman,54 and, as a result, we produced intercoderagreement among the 3 coders at over 90% for each ofthe 3 coding definitions.

The clinical reasoning strategy codes were developed bythe panel based on Jensen and colleagues attributedimensions18 and other described clinical reasoningmethods used in health care such as narrative reason-ing.27 That is, alongside the existing descriptions ofclinical reasoning used in fields such as nursing andoccupational therapy, the attribute dimensions provided

* Velcro USA Inc, 406 Brown Ave, Manchester, NH 03103.



8/19

Figure 3.Overview of case study formation.



9/19

areas of clinical practice (eg, teaching, psychosocialfocus, prognostic ability) among expert practitioners inwhich to examine foci of clinical reasoning.

The knowledge frameworks and sources of knowledgecoding definitions were adapted from Jensen et al.19(p71)

The knowledge framework codes included physical ther-

apists content knowledge of their field or speciality,their knowledge of patients (including of human behav-ior), a knowledge of teaching, a knowledge of self(including evidence of reflective ability, confidence, andgrowth as a person and as a professional), and a knowl-edge of context (relating more to understanding thelarger picture and the role of their work, the workenvironment, and the workings of the health care sys-tem). The sources of knowledge codes included per-ceived influences from mentors, patients, colleagues,friends and others, professional education (outside ofthat received during formal training), self-education,reading, life events (happenings in life outside practicethat cause reflection on a clinicians own clinical work),and research in which the therapist had personally beenengaged.

A typology of knowledge proposed by Higgs andTitchen,11which represents 3 types of knowledge used inclinical practice (propositional, professional, and per-sonal), was later adopted as a conceptual framework tocharacterize the dimensions of knowledge described.Propositional knowledge refers to public or declarativeknowledge in a particular field or part of the externalworld. Professional knowledge refers to forms of practice

knowledge, often tacit or intuitive, that also reflect apractitioners practical and technical expertise. Personalknowledge is experiential knowledge that comes aboutthrough the practitioners reflection on experience(both work and nonwork related) and helps form apractitioners frame of reference or worldview with itsparticular values.

In our study, individual case studies describing theclinical practice of each therapist from the primarysample, particularly in terms of the scope of clinicalreasoning, were constructed drawing on the data

obtained through the observations, interviews, and time-lines (Fig. 3). Impressions from the field notes wereadded to these data sources. Each case study was sent, oncompletion, to the respective therapist from the primarysample for his or her comments, a process known asmember checks.52 On follow-up, which was done via atelephone conversation, each therapist responded verypositively to the question, Was the case study a fair andaccurate interpretation of their clinical work with itsparticular characteristics, emphases, and values?

The process of case study analysis was done in thefollowing sequence. Individual case studies for each areawere combined with the coded material from the inter-views of the secondary sample of physical therapistexperts to form 3 composite case studies. From thesecomposite case studies, cross-case analysis, first withinsettings and then across settings, was performed. Table 3

illustrates how conceptual frameworks (explanationsbuilding on previous understandings) were developediteratively with this data collection and analysis process.

Ensuring RigorThere is much debate concerning rigor in qualitativeresearch.47 In our study, a range of strategies were usedto strengthen the integrity of the studys findings. One ofthese strategies, member checks,54 has already been men-tioned in relation to the primary sample. Other strategiesused in the study include negative case analysis,39,54 anaudit trail,55 thick description,56 and triangulation.50

Negative case analysisoccurs where incidences of data thatdeviate from the overall patterns of data are pursued asan opportunity to refine and review a conceptual frame-work under development. One example in our study waswhere the physical therapists expressed regret or failure.These feelings were pursued and explicated in the casestudies. An audit trail is a record of decision making(either of the primary investigator or of the codingpanel), of turning points in the research, of correspon-dence with various stakeholders, and of cognitiveroadmaps summarizing researcher understanding of theproject at different points. Thick descriptionis an anthro-

pological term56 referring to an in-depth description ofparticular and multiple characteristics of a case (ie, aparticular therapists clinical practice) in order to inductthe reader into an experience of the situation. Thisin-depth description reduces the chance that identifiedelements of observed treatment sessions or interviewcomments from informants aretaken out of contexttosuit the purposes of the researcher. Examples of thickdescription are provided in the Findings section. Tri-angulation is an important tool used in an effort toensure rigor and involves the use of several data sources,methodological approaches, multiple analysts, and the

consideration of diverse theories to explain findings inorder to reduce systematic bias in the data.50,54 In ourstudy, the different data sources were observation, inter-view, and written reflection. There were positivisticmethods (eg, coding reliability) juxtaposed with natural-istic methods (eg, thick description). Multiple analystsconsidered coding definitions and identified the result-ing constructs from the data. Finally, multiple perspec-tives were considered: the constructed case studies,which were the interpretations of each therapists clini-cal practice by the researchers, the corroboration ofthose case studies by each therapist in the primary



10/19

Table3.

TheIterativeNatureofGroundedTheory

andCaseStudyWork

Time

Literature

Da

taCollection

DataAnalysis

ConceptualFram

eworks

April1996

November1996

February1997

May1997

December1997

December1998

June1999

January-August2000

Ethicsproposal

Literaturereview1

Literaturereviewcontinuing

qualita

tivemethodology

clinica

lreasoning

clinica

lpracticeissues

modelsofpractice

professionalsocialization

philosophiesofknowledge/research

Literaturereview2

adultlearning

ethics

social

theoriesoflearning

Reviewofliteraturereviews1and2

Shadowingtherapists

(observation,interview)

2

Tim

elinereflections

Interviewswithother

physicaltherapists

Researchfolder:

memos,

communications,

reflections,

paneldecisions

Reflectionondaily

experien

ces

2

Transcriptpreparation,

codingmeetings

2

Individual

casestudies

2

Therapistc

orroboration

2

Composite

casestudies

2

Crosscase

analysisand

thematic

write-up

2Finalwrite-up

Attributedimensions(Jensenetal,18

1992),existingliteratureformsof

reasoning

2

Clinicalreasonings

trategies1.

fociofthinkingan

daction

Knowledge:Jensenetals(1996)

framework(citedinJensenetal,19

1999)

2

Clinicalreasonings

trategies2.

combinationsofcue-basedreasoning

Knowledge:HiggsandTitchen,11

2000personal,professional,and

propositional 2

Clinicalreasonings

trategies3

dialecticalrelation

shipbetweendifferent

paradigmsofreasoning

Knowledge:individualandsocial

learningincommunitiesofpractice



11/19

sample, together with the views of the second sample oftherapists (incorporated in the composite case studies)were all compared with existing models of reasoningfrom the relevant literature.

FindingsWe used 3 stages in the conceptualization of the clinical

reasoning: (1) identification of different clinical reason-ing strategies, (2) cue-based combining of reasoning strat-egies, and (3) interplay of reasoning strategies in differentparadigms of knowledge leading to the final proposedmodel of clinical reasoningdialectic reasoning.

First Conceptual FrameworkClinical Reasoning StrategiesClinical reasoning strategies can be thought of as a wayof thinking and taking action within clinical practice. Anumber of different reasoning strategies were evidentwithin the expert case studies and identified as beingcommon to the practice of all of the physical therapistsacross the 3 fields. We considered these strategies underthe broad headings ofdiagnosisand management:

Diagnosis

Diagnostic reasoning is the formation of a diagnosisrelated to physical disability and impairment withconsideration of associated pain mechanisms, tissuepathology, and the broad scope of potential con-tributing factors.

Narrative reasoning involves the apprehension andunderstanding of patients stories, illness experi-

ences, meaning perspectives, contexts, beliefs, andcultures.

Management

Reasoning about procedure is the decision makingbehind the determination and carrying out of treat-ment procedures.

Interactive reasoning is the purposeful establishmentand ongoing management of therapist-patientrapport.

Collaborative reasoningis the nurturing of a consen-

sual approach toward the interpretation of exami-nation findings, the setting of goals and priorities,and the implementation and progression ofintervention.

Reasoning about teaching is thinking directed to thecontent, method, and amount of teaching in clini-cal practice, which is then assessed as to whether ithas been effectively understood.

Predictive reasoningis the active envisioning of futurescenarios with patients, including the explorationof their choices and the implications of thosechoices.

Ethical reasoning includes the apprehension of ethi-cal and practical dilemmas that impinge on boththe conduct of intervention and its desired goals,and the resultant action toward their resolution.

Second Conceptual FrameworkCue-Based Combiningof Reasoning Strategies

In the second conceptual framework, we acknowledgedthe fluidity of clinical practice. Clinical practice wasobserved to consist of several dynamics or actions thateither were happening at once or were closely juxta-posed to one another. In this conceptual framework, theclinical reasoning strategies were combinations of cue-based reasoning where there was interdependenceamong various strategies at any given time. That is, inagreement with Jensen et al,18 although these therapistshad frameworks for information gathering and carryingout procedures, they did not follow a strict order ofprotocols in clinical practice. Instead, they attended tothe cues provided by patients:

And I dont always know when I start with them how Imgoing to . . . you know . . . what path Im going to take, if

you see what I mean. I dont have a recipe, but I tend to betriggered by what they say and then move them from there.(Neve, neurological therapist)

I tend to let the person guide the interview. And then, at theend, I think we havent covered shopping or we haventcovered toileting or pressure care or whatever the gaps are. SoI guess I have got that sort of internal list, and I work out whathasnt been covered at the end. But I let the person take it forthe first while. Im not very good at sitting with someone with

a form and saying tick, tick, tick down the form. Itdoesnt work for me. (Denise, domiciliary care therapist)

I actually think their information is more important thanyour own sometimes because thats the most powerful partof the relationship with them . . . and with subjectives [sub-

jective examinations], Ill never write them up afterwardsbecause its just . . . its so much information youre getting,and its such valuable stuff. (Michael, orthopedic [manual]therapist)

The following vignette illustrates how clinical reasoningstrategies may be used in combination and is drawn from

the field notes (and later discussion) of an observedtreatment between manual therapist Michael and hispatientT:

Thas continued pain following diskectomy 5 weeks previ-ously. He reports that his leg symptoms have reduced by50%. However, he is distressed by continued backache.

Ts distress, the way he walks in, the expression on his face,and his subdued manner provide initial cues that arerecognizable features or patterns lodged in Michaels clin-ical knowledge. Michael realizes that there are likely to beother contributing factors in Ts present pain experience



12/19

apart from that emanating from the operated disk. Whatthose factors are will need to be explored. Outside ofdiagnosis, hypothesis formulation and testing will be

required in a number of areas. In the area of interactionalone, what will be the best way to gain Ts confidence?

Following assessment of symptom behavior, T undresses,and ropes of paraspinal muscle spasm are noted byMichael. A few minutes into the physical examination, T,himself, provides a cue that Michael immediately followsup: When I take a deep breath, my pain is eased for aminute. Michael asks Tto demonstrate this, observes theaction, and, in response, teaches him how to enhance theeffect by contracting the transversus abdominis muscle.

What occurs now is the combined use of teaching and

diagnostic reasoning; one informing the other. Havingenhanced Ts own method of pain relief by transversusabdominis muscle contraction, Michael decides to teachhim further about the relationship of the muscle behaviorto his pain. He proceeds to carefully re-educateTs lumbarspine movement in various positions by controlling andreleasing the lumbar extensor muscles.

On reassessment of lumbar flexion movement, both patientand therapist agree that it is substantially better, although Tis still tense and in pain. Thus, reasoning simultaneously inthese 2 areas of diagnosis and teaching has strengthenedthe hypothesis that at least one contributing factor to Tspain is an adverse and sustained tension in the lumbarextensor muscles.

Although 2 or more clinical reasoning strategies may bein operation concurrently and there may be overlapbetween the reasoning strategies (eg, interaction andcollaboration), each clinical reasoning strategy requiresan orientation of thinking and action, which is notwholly subsumed by the others.

Third Conceptual FrameworkInterplayof Reasoning Strategies in DifferentParadigms of Knowledge GenerationThe third and final conceptual frame-work involves the dialectical nature ofreasoning within the clinical reasoningstrategies. A dialectic is a debate

intended to reconcile a contradiction(in this case between fundamentallydifferent processes of reasoning) with-out attempting to establish either viewas intrinsically truer than the other.57

The term dialectical reasoning wasused in our study to describe an inter-play between the different paradigmsof knowledge and reasoning processesthat are expressed in each of the vari-

ous clinical reasoning strategies (as exemplified in thedata). This interplay is summarized in Figure 4.

The 2 research paradigms (as discussed in the introduc-tion) generate knowledge from different assumptionsabout the nature of reality. Therefore, the clinical rea-soning processes diagnostic reasoning and narrativereasoning, as described in clinical reasoning litera-ture,10,16,26,29 are representative of these different para-digms of knowledge and reasoning. The clinical reason-ing strategies of interaction, procedure, teaching,collaboration, prediction, and ethics represent foci ofclinical decision making or action in areas of patientmanagement that may be oriented in either paradigm atparticular times within a clinical encounter.

The terms narrative and communicative and theterms hypothetico-deductive and instrumental, asapplied to the reasoning strategies, may be consideredsynonymous. However, the terms hypothetico-deductiveand narrative,in emanating from the clin-ical reasoning literature, have traditionally been appliedto the process of inquiry or diagnosis in clinicalpractice.10,29 The terms instrumental and communi-cative,in emanating from the literature of adult learn-ing, are here applied to a range of learning and actiontasks and are therefore, we believe, more appropriately

applied to the diversity of clinical management strate-gies. For example, assessment leading to identification ofspecific exercise needs would fall into the hypothetico-deductive inquiry framework whereby the specificinstruction, correct execution, feedback, and ultimatelearning of the exercise would be described as a form ofinstrumental management. Similarly, exploration of apatients perspectives regarding his or her problem,including the patients understanding (or beliefs andattributions), expectations, and coping, are examples ofnarrative inquiry where management directed towardfacilitating reflection and consideration of alternative

Figure 4.Summary of the relationship between knowledge and reasoning paradigms with clinicalreasoning strategies.



13/19

perspectives (by patient and therapist) would constitutecommunicative management.

The data in our study took the form of dialoguesregarding treatments and interviews, and the length ofthese dialogues (thick description) created constraintson presenting examples of instrumental and communi-

cative approaches to each reasoning strategy by eachtherapist or even within each field. Due to the con-straints of space, the reasoning strategies are not pre-sented in equal detail. However, all of the reasoningstrategies illustrate the dialectical nature of the physicaltherapists reasoning and can be found in more detailonline in the nonpeer-reviewed doctoral dissertationon the research project.58 Diagnostic and narrative rea-soning, being well documented in the clinical reasoningliterature and having been explained in the backgroundsection, will not be further dealt with here, althoughpatient stories (or fragments of them) are included asexamples in the reasoning strategies of interaction,teaching, and ethics.

The Clinical Reasoning StrategyInteractionThere is no question that the physical therapists in ourstudy often appeared to socialize or interact with theirpatients out of pure enjoyment. On the many occasionsin which the therapists were observed to divulge aboutthemselves, for example, sharing stories concerningtheir families, this was almost always a purposeful activity.Sometimes this was done to gain the confidence of thepatient or facilitate the engagement of the patient in thetreatment session. The use of humor for this purpose

also was observed. Consider these first exchanges in aninitial treatment session with Neve (neurological thera-pist) and her patient, who had entered the room ner-vously:

Neve: Are you working, M . . . ?

M: I work 2 days a week as an occasional registered nurse atSt A . . .s.

Neve: Ive got a daughter whos just finishing nursing, andshes at Repatthe last day of her course. She told me they

were going to give her a Betadine bath to mark the

occasion [joint laughter].

M: As long as she doesnt come home with a cast on herarm.

Neve: Now you saw Dr B. . . . Did he give you a letter at all?

This kind of interaction wasinstrumentalinsomuch as itwas carried out to produce a particular effect. In this

case, it was to put a nervous patient at ease and expediterapport. At other times, the instrumental nature ofinteraction was even more pronounced, with the inter-action obviously controlled by the physical therapist andcharacterized by closed questions. For example, duringsome manual therapy techniques, patients were asked torespond only by stating numbers between 0 and 10. This

quantitative expression of symptoms, which might lastseveral minutes over the duration of the technique, wasfar removed from any narrative component. Here painwas metaphorically manipulated as a variable in theintervention that was carried out. In these cases, inter-action was simply a measure gauging the success oftechniques that were being carried out.

Interaction, however, could be quite communicatively(ornarratively) focused. At such times, interaction was char-acterized by open-ended questions with the purpose ofsimply understanding or finding out more about apersons values, beliefs, or assumptions regarding his orher (or his or her partners) illness or treatment. Anexample of this is found in domiciliary care therapistDanielles visit to an elderly couple of Croatian origin.Mr G had terminal cancer. The visit had been veryproblem oriented, without any particular expression ofhow MrGor his wife was feeling about the situation. MrGsdaughter had been present and acting as interpreter.Danielle, aware of the time and the days other commit-ments, nevertheless, precipitated what was to follow witha simple question:

Danielle: Is there anything we havent covered that you

think we really need to?

Daughter: He [indicating her father] reckons the one thinghe wants to know nobody wants to tell him: how long hesgot to live!

Wife: I wouldnt want to know [pointing to her husband].Never sick [in the past] . . . just cold . . . cough.

Daughter: Shes actually terrified. She panics.

Danielle said nothing. It was not, however, a silenceborne of awkwardness. There was a receptiveness in

Danielles attention that was not only comfortable withthe momentary pause in conversation but then createdthe space and opportunity for the husband and wife toreflect with poignancy on their lives since coming toAustralia. They spoke of the richness of their marriedlife, describing their early years after immigration toSouth Australia, working long hours on their fruit blockin the Riverland. This was the wonderful setting in whichtheir children grew up. Husband and wife related whateach was doing now. By the end (perhaps 10 minutes),MrsGwas able to give gentle expression to the tears thathad been rising but held so far during the visit.

The Purdue Frederick Company, One Stamford Forum, Stamford, CT 06901-

3431.



14/19

The Clinical Reasoning StrategyProcedureBy far the most commonly observed procedure acrossthe 3 fields was the therapeutic use of movement.Movement, as a procedure, includes several subcatego-ries: touch, handling, palpation, massage, mobilization,manipulation, stretching, and guided exercise. Variousscenarios focusing on movement as a procedure were

described in the case studies. Almost always the use ofmovement in intervention was a highly instrumentalprocedure (ie, techniques were selected and applied andtheir effects were measured and predicted throughreassessment of range of motion and so forth). However,movement could also, at times, be a highly communica-tive action where handling, touch, and massage wereused to convey therapist attitude or empathy (ie, mean-ing and intent) and were not assessed in any measurableway. Interviewed domiciliary care therapist Dianneexpresses this idea:

My hands can actually do more than just about anything,

and sometimes . . . most times theyre more powerful thanwhat you can say anyway . . . putting hands on someone canspeak enormous amounts.

The following example was taken from field notes writ-ten while observing neurological therapist Narelle atwork. Her patient,N, had a particularly aggressive formof multiple sclerosis. She was attending the treatmentsession with her caregiver and friend H. It was not longsince Nceased being able to look after herself and wasforced to go into a nursing home. She was not an oldwoman, yet she gave an impression of feeling it to be so.

N was depressed and, understandably, experiencedmood swings. Narelle, in the session, had been workingon tightness inNs foot. The treatment atmosphere hadbeen loud (particularly on Narelles part) and alsoaction filled. At one point, Narelle was called to thetelephone. While she was away (no more than 2 min-utes),Nbegan to cry. When Narelle returned, she got invery close, softened her voice, and cradled Ns left armwithout speaking further for a short time. This wasdespite the fact that prior to the telephone call, she hadbeen working on Ns foot. After a silent moment, Nuttered, in response to Narelles proximity rather than toany question: God, its heavy! The session then slowly

resumed its course.

The Clinical Reasoning StrategyTeachingTeaching was a ubiquitous activity in the practice of all ofthe physical therapists in our study. The scope of teach-ing included information provision, instruction, advice(including informal counseling), and explanation.

Examples of instrumental teaching were numerous.Domiciliary care therapist Denise taught MrH, who hada stroke, how to get up and down off a chair indepen-dently. The maneuverrising from a sitting position to

a standing positionrequired consideration of the pos-sible contribution of several factors affecting its success-ful completion: Mr Hs position on the chair (buttocksforward), the position of his feet, the flexibility of hisknees, the height of the chair, and the use of arms topush off. Denise addressed each factor, hypothetico-deductively confirming or negating the influence of

each factor in MrHs inability to rise from the chair. Theoutcome of her intervention was measurablewhat MrHcould not do initially, he could do now. Many otherexamples of exercise instruction were similar to this.

A very different form of teaching communicativeteachingwas observed when Neve (a neurological ther-apist) sought to provide a means by which M, a youngmother with tension headaches, could become awarehow teeth clenching could result from a number ofdifferent behaviors.

Neve: I had a guy who was a plasterer, and he had terrible

headaches, and I said to him, What do you notice happen-ing? . . . and he really didnt notice very much. But heasked the people whom he worked with, and he said, Well,how do I look when Ive got a headache? and they said,You smile all the time, and he realized he was clenchinghis teeth, trying to look like he wasnt in pain . . . but teethclenching was really perpetuating the headaches. So its notthe whole story of headaches, but sometimes the teethclenching can be a problem, especially if there is a lot to doand not a lot of time to do it in. Sometimes we get into thehabit of just gritting our teeth and . . . keeping going when

were in pain. Its sort of a chicken and egg thing. I dontknow what comes first, whether the teeth clenching comes

first or the headache.

A strong theme in the earlier part of this initial sessionhad beenMs poor coping mechanisms and unresolvedconflict with other family members. Some of this conflicthad derived from Ms inability to keep her house main-tained to the standards that she would like. Having a2-year-old son was not helping her in this endeavor andneither were the high expectations of her mother-in-law.The story that Neve told Mregarding the plasterer withheadaches appeared to have the aim of providing herwith the insight that people sometimes may be unawarethat their own responses, or coping behaviors can con-tribute to the production or perpetuation of symptoms.Thus, the plasterer, who in response to Neves question,What do you notice happening? (when he had theseheadaches), asked his workmates what he looked likeand was told that he smiled all the time.The plastererthen realized that he was clenching his teeth, trying tolook like he was not in pain, but in doing so wascontributing to further headache symptoms.

Neves purpose in telling this story had been to encour-age M to reflect less on the outcome of her stressorsand more toward her own responses to these stressors as



15/19

possible factors contributing to her headaches. This is acommunicative form of teaching: What perspectivesdoes M hold concerning her situation that are eitherunreliable or unhelpful?

The kind of communicative teaching used was accompa-nied in the same session by Neves teachingM,in a more

instrumental way, how to recognize increased tension inher temporalis and masseter muscles and to then be ableto use relaxation techniques to decrease these factors.Thus, we considered both forms of teaching, the instru-mental and the communicative, essential components ofsound management ofMs headaches. We believe thereis an intrinsic relationship between the instrumental andcommunicative forms of management for each of thereasoning strategies.

The Clinical Reasoning StrategyCollaborationCollaboration was observed to be about the meeting ofperspectives: the therapists with the patients (or care-givers). The nature of certain procedures precludedapart from a more generalized consent or imprimaturthe therapist consulting the patient or asking his or herpermission at every decision point. Collaboration at suchtimes was necessarily instrumental. In instrumentalforms of collaboration, the patient, through either animplicit or explicit negotiation with the therapist, wasobserved to place himself or herself (even if only forspecific durations within a treatment session) in thehands of the expert practitioner. For example, thetherapist would say, Lift your arm or Push harderand the patient either did or did not do it. Its effect was

observable and, to this extent, empirical. ConsiderNarelles (neurological therapist) work with her patient

J, who had hemiplegia as a result of surgery to remove ananeurism:

Just try and drop that wrist down . . . slowly! Dont pushdown at your shoulder! Dont push down at your shoulder!

Just relax it. Just think about rotating at the elbow.

and,

Lift those toes right up for me and let them down . . . andlift them up, right up . . . cmon, cmon . . . cmon toes get

moving . . . and drop down. And lift them up and drop. Andlift them up. Alright?

Communicative approaches to collaboration wereobserved in all settings, but were particularly found inthe domiciliary care (home health) setting. Daniellespoke positively of a power shift from therapist topatient:

The power difference is not the same as in the hospital.Theres none of this, Do this because I say so.People saynoto you more often in this setting than they ever would,

even in your rooms or as an outpatient in the hospital;definitely as an inpatient in the hospital. So its goodbecause theres no point in them saying, Yes, theyll dosomething if theyre not going to.

A communicative approach to collaboration emphasizesthe plurality of choices and the necessity of means toends approaches to problem solving that relate to apersons values and beliefs. It is not only this transfer ofmeaning (ie, where the intentions of the therapist andthe perspectives of the patient are communicated andmutually understood) but also the transfer of power(ie, the therapists letting go of a professional righttobe right in favor of the patients assumption of a greatervoice) that constitutes the move to a communicativeapproach to collaboration. The instrumental and com-municative forms of collaboration are not being setagainst one another, and both could occur within asingle treatment session.

The Clinical Reasoning StrategyPredictionPrediction as a task in clinical practice was found to varyamong settings. Prediction included such decisions aswhen athletes could return to their sport or wheninjured workers could return to their jobs. Predictivereasoning also could be used to assess the potentialbenefit a person who had a stroke was likely to obtainfrom physical rehabilitation. However, predictive reason-ing was at times required in quite a different way toanswer more existential questions pondered by thosewith terminal disease, or recalcitrant neurological con-ditions, or chronic pain states who asked either implicitly

or explicitly:What does the future hold for me?Suchvariations required quite different paradigms of reason-ing. Again, both forms would frequently be identifiedwithin the one treatment scenario.

The Clinical Reasoning StrategyEthicsEthical problems were seen to take various forms withinthe 3 fields. A major source of ethical dilemmas inclinical practice revolved around problems associatedwith resource allocation. These problems took differentexpressions according to setting. For example, in domi-ciliary care, these problems often involved access issuessuch as waiting lists and availability of equipment,

whereas, in manual therapy, these problems took theform of determining adequate and fair treatment timesand billing issues. Ethical dilemmas arose from complexsituations within therapy encounters as the followingexample illustrates.

Neurological therapist Narelle works with J, who hadhemiplegia and was introduced in the collaborativereasoning section.Js husband, Bob, is in attendance. AsNarelle works with Jto alleviate stiffness and abnormalreflex activity in the lower limb, the conversation takes aturn, one that reaches a point of unexpected intensity. It



16/19

concerns a 17-year-old boy, known to both Jand Narelle,and his experience after a subarachnoid hemorrhage 3years previously. He now has severe cerebellar ataxia.The story provokes reflection byJon her own situation.It also leads to Narelle being confronted with an ethicaldilemma. All this occurs as intervention continues (stillmonitored) on the foot.

J: Got a long way to go, and its been 3 years . . . and himand his brother had tests to see if its hereditary, and theysaid, Youve got no worries.

Narelle: Well, you cant tell.

J: No, you cant tell. Its an awful thing to happen.

Narelle: Well, my mums father died of one, and my sistershad one, so . . . [with an ironic laugh] they do run infamilies unfortunately. [Narelle is currently doing intertar-sal glides.]

Wheee! [as she provokes some increased tone from Js bigtoe muscles]

J: Well, Ive suffered from headaches since I was 16, wellover 30 years, and Im sure it must have been my aneurism.

Narelle: But the statistics, J, are that 1 in 4 of us have somekind of malformation to our brains because its such anincredibly intricate structure.

J: But when it happens to you . . .

Narelle: But a lot of people never have problems, but justoccasionally people will. Theres not a lot you can do.

J: I never heard of it until it happened to me, and theneveryone you speak to. . . . I spoke to someone yesterday.

Bob: What gets me is that they know what the side effectsare, but they still go ahead and do the operation.

Narelle: The side effects of the operation?

Bob: h-uh. . . . They still go ahead and do the operation,they just chalk up: Huh, theres another life Ive saved.

J: Bobs a bit bitter about it.

Bob: Oh bitter? Id cut the bastards hands off if I could.

J: Thats because I was told that I would havemighthavea minor stroke, and I dont think this is . . .

Bob: Might have a slight little bit of paralysis thatll only lasta few weeks.

J: But I mean if I had the ultimatum, what do I do? Do I havethe operation to cut the aneurism off?

Narelle: I dont know. I dont know about the history. Icouldnt really comment.

J: Mmmm. Well, my aneurism was leaking, so I mean itneeded to be done straightaway.

Narelle: It probably had to be done.

Bob: Because when I asked, whats his name, Dr Squirrel [asarcastic nickname given by Bob], Whats the percentagethat [in] these operations theres nothing goes wrong?hesaid, Zero, theres always something goes wrong.

J: Well get there.

Narelle: Well, thats actually not completely true. My sisterhad an operation, and shes fine. Sometimes probably its abit more difficult to control, I dont know.

[addressing J] Im really going to cut this toe off!

J: Yeah, you can if you like.

Narelle: Would you mind?

J: Nah!

Narelle has just had to pilot her way through a situationwhere, she needed to acknowledge Js disappointmentand Bobs burning anger toward the surgeon and surgi-cal management of Js aneurism. She also needed toexpress another perspective about outcomes in suchcases. Working with neurologists and neurosurgeons on

a regular basis, Narelle is aware of some of their realities.In Js situation, Narelle decides not to make any defini-tive comments about whether or not she would havebeen better not to have had the surgery. She mildlycorroborates Js own statement that it needed to bedone straightaway.Interestingly, she does nottoeanyprofessional line as such, feeling content to contradictDr Squirrelsalleged remark thattheres always some-thing goes wrong with the contrasting example of herown sister. Narelle apparently decides that there isnothing further she can add to the present conversationand returns the focus, through her cutting off the bigtoeremark, to the foot that is being mobilized.

The ethical reasoning that has taken place exhibitsrecognition of the particular faces (patterns) of patientor caregiver anger. Although not necessarily evokingready-made or protocol-based solutions to such dilem-mas, nevertheless some elements of Narelles learnedexperience are brought into action at these times: theimperative to listen carefully to and take seriously thepatients or caregivers feelings or complaints; theimportance of determining perspective and the com-pleteness of the story; and the knowledge that herresponse is not only sought by the patient or caregiver



17/19

but will generally be considered to carry weight, and soit must be a wise and responsible response that doesjustice to all parties. Narelle appears to act from theseprinciples, and yet there is that self-revelation both at thebeginning and near the end of the interaction thatpersonalizes her perspective. Her response to Bob and Jis not wholly based on a detached set of principles.

Narelle is able to introduce an experiential componentto her response with the introduction of her own sistersexperience. She chooses to contradict the medicaldefense.Narelle has been a witness in this situation toa narrative protesting the havoc of iatrogenesis (ormedically induced harm to the patient). Such narratives,with their experiential truth and passion, compelre-examination of medical (and other health care prac-titioners) practices and precepts.59

The dialectic nature of clinical reasoning continues,therefore, in ethical decision making. On the one hand,there is ethical decision making as the application ofnormative or professional rules and principles to partic-ular situations in a deductive or instrumental manner.Patient autonomy, justice, and not doing harm topatients are examples of such principles.60 On the otherhand, there is a narrative (or communicative) approachto ethical decision making where the experiential andcontextual elements of a given situation (or narrative)guide decisions and actions, in turn, providing perspec-tives on these broader rules or principles of right andwrong.61

Discussion

Previous clinical reasoning literature has proposed dif-ferent reasoning processes for particular tasks in clinicalpractice (eg, procedural [ie, doing something to thepatient] reasoning versus interactive [ie, knowing thepatient] reasoning).26,28 We found that there was aninterplay of different reasoning processes in every task ofclinical practice, suggesting both a complexity and scopeof clinical reasoning activity not previously understood.

Our findings support existing research19,20,26,28 concern-ing the attention given, and importance attributed, tothe interaction between practitioners and their patients

in a range of areas such as therapist-patient interaction,collaboration, teaching, and ethical practice. Unlike theseminal works in clinical reasoning in the allied healthfields,19,26,29 however, our study leads to conclusions thatdo not seek so much to draw the contrast (and distance)between cognitively based, rational models of reasoning(eg, hypothetico-deduction) and interactive or meaning-based forms of reasoning (eg, the use of narrative).Rather, we contend that our conclusions concentrateon illustrating their intrinsic relationship in clinicalpractice.

The dialectical model of clinical reasoning arising fromour study is depicted as reasoning that moves betweenthose cognitive and decision-making processes requiredto optimally diagnose and manage patient presentationsof physical disability and pain (hypothetico-deductive orinstrumental reasoning and action) and those requiredto understand and engage with patients(or caregivers)

experience of that disability and pain (narrative orcommunicative reasoning and action). Hypothetico-deductive or instrumental reasoning and action involvesphysical therapists engaging in critical reflection of theunderlying assumptions (ie, hypothesis testing) behindthe content and process of their own decision-makingand knowledge structures. Critical reflection in narrativeor communicative reasoning and action, however,involves physical therapists endeavoring to understandthe assumptions underlying patients beliefs and deci-sion making and to communicate their own assumptionsto the patient. Following consensual validation of theseassumptions with their patients, we propose that com-municative management then also involves physical ther-apists fostering a process of critical reflection on the partof patients regarding the reliability and adequacy ofthose assumptions as exemplified by neurological phys-ical therapist Neves work with her patientMin facilitat-ing an understanding of her tension headaches.

Dialectical reasoning, with its notions of instrumentaland communicative management, fits well with recentmodels of health and disability such as the biopsycho-social model62 and the World Health Organizations(WHO)International Classification of Functioning, Disability

and Health.63 For example, in the WHO classification thefunctioning of an individual in a given setting is aninteraction or complex relationship between the healthcondition and contextual factors.62(p19) There is, there-fore, an interaction between activity limitations(difficul-ties an individual may have in executing activities) and

participation restrictions (problems an individual mayexperience as a consequence of his or her involvementin life situations). It is recommended that health carepractitioners collect data on these constructs indepen-dently and thereafter explore associations and causallinks between them.63(p19) The clinical reasoning model

proposed here offers physical therapist clinicians aframework to be able to explore (and act in) thedynamic interaction of activity limitations and participa-tion restrictions.

SummaryWe found that all of the observed physical therapists ineach of the 3 settings used a range of clinical reasoningskills or strategies representing a diversity of thinkingand actions in a variety of tasks and relating to manyissues that exist in clinical practice. These skills orstrategies range from the act of making a diagnosis



18/19

through management issues through ethical decisionmaking. These therapists used these reasoning strategiesin an interplay that was governed by particular patients needs and their contexts.

The grounded theory underpinning this dialecticalmodel represents the development of a series of concep-

tual frameworks describing clinical reasoning. In arriv-ing at this model, the data concerning clinical reasoningstrategies and therapists use of knowledge has, in themanner of grounded theory, been repeatedly comparedand reapplied to existing theories or literature in rele-vant areas such as clinical reasoning, paradigms andtypologies of knowledge, and the more formal theoriessuch as Habermas Critical Social Theory33 and Mezi-rows Transformatory Learning Theory.35 Our modeldraws on these theories but in a manner that recontex-tualizes them in relation to the data of this study inparticular and the scope of clinical reasoning in physicaltherapy in general.

References1Higgs J, Jones MA. Clinical reasoning in the health professions.In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions.2nd ed. Boston, Mass: Butterworth-Heinemann; 2000:314.

2Ritchie JE. Building a customer perspective into evidence-basedphysiotherapy practice. In:Proceedings of the Fifth International Congress ofthe Australian Physiotherapy Association; Hobart, Tasmania, Australia. Vol1. Hobart, Tasmania: Australian Physiotherapy Association (Tasma-nian branch); 1998:9799.

3Higgs J, Hunt A. Rethinking the beginning practitioner: introducingtheInteractional Professional.In: Higgs J, Edwards H, eds. EducatingBeginning Practitioners. Melbourne, Victoria, Australia: Butterworth-

Heinemann; 1999:1018.4Payton OD. Clinical reasoning process in physical therapy.Phys Ther.1985;65:924928.

5Thomas-Edding D. Clinical problem solving in physical therapy andits implications for curriculum development. In:Proceedings of the TenthInternational Congress of the World Confederation for Physical Therapy; May

1722, 1987; Sydney, Australia. London, United Kingdom: World Con-federation for Physical Therapy; 1987:100 104.

6Proceedings of the APTA Conference on Clinical Decision Making inPhysical Therapy Practice, Education, and Research; October 25,1988; Osage Beach, Missouri.Phys Ther. 1989;69:523 617.

7 Hypothesis-oriented algorithm for clinicians: a method for evalua-tion and treatment planning. Phys Ther. 1986;66:13881394.

8Jones MA. Clinical reasoning in manual therapy. Phys Ther. 1992;72:875 884.

9Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-OrientedAlgorithm for Clinicians II (HOAC II): a guide for patient manage-ment.Phys Ther. 2003;83:455 470.

10 Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving: AnAnalysis of Clinical Reasoning. Cambridge, Mass: Harvard UniversityPress; 1978.

11Higgs J, Titchen A. Knowledge and reasoning. In: Higgs J, JonesMA, eds. Clinical Reasoning in the Health Professions. 2nd ed. New York,NY: Butterworth-Heinemann; 2000:2332.

12Schmidt HG, Boshuizen HPA, Norman GR. Reflections on thenature of expertise in medicine. In: Keravnou E, ed. Deep Models forMedical Knowledge Engineering. Amsterdam, the Netherlands: Elsevier;1992:231248.

13Patel VL, Groen GJ. Knowledge-based solution strategies in medicalreasoning. Cognitive Science. 1986;10:91116.

14 Feltovich PJ, Barrows HS. Issues of generality in medical problemsolving. In: Schmidt HG, Devolder ML, eds. Tutorials in Problem-Based

Learning. Assen/Maastricht, the Netherlands: Van Gorcum; 1984:128141.

15Arocha JF, Patel VL, Patel YC. Hypothesis generation and thecoordination of theory and evidence in novice diagnostic reasoning.Med Decis Making. 1993;13:198 211.

16Rogers JC, Masagatani G. Clinical reasoning of occupational thera-pists during the initial assessment of physically disabled patients.Occupational Therapy Journal of Research. 1982;2:195219.

17Jones JA. Clinical reasoning in nursing. J Adv Nurs. 1988;13:185192.

18Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute dimensionsthat distinguish master and novice physical therapy clinicians inorthopedic settings. Phys Ther. 1992;72:711722.

19 Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in PhysicalTherapy Practice. Boston, Mass: Butterworth-Heinemann; 1999.

20Beeston S, Simons H. Physiotherapy practice: practitioners per-spectives. Physiotherapy Theory and Practice. 1996;12:231242.

21Benner P. From Novice to Expert: Excellence and Power in ClinicalNursing Practice. London, United Kingdom: Addison Wesley; 1984.

22 Benner P, Tanner C. Clinical judgment: how expert nurses useintuition.Am J Nurs. 1987;87:2331.

23Rew L, Barrow EM. Intuition: a neglected hallmark of nursingknowledge. Advances in Nursing Science. 1987;10:49 62.

24Agan D. Intuitive knowing as a dimension of nursing. Advances inNursing Science. 1987;10:6370.

25Benner P, Tanner C, Chelsa C. From beginner to expert: gaining adifferentiated clinical world in critical care nursing.Advances in NursingScience. 1992;14:1328.

26Benner P, Tanner C, Chelsa C. Expertise in Nursing Practice: Caring,Clinical Judgment, and Ethics. New York, NY: Springer Publishing Co;1996.

27Mattingly C. The narrative nature of clinical reasoning. Am J OccupTher. 1991;45:998 1005.

28Fleming MH. The therapist with the three track mind. Am J OccupTher. 1991;45:10071014.

29Mattingly C, Hayes Fleming M.Clinical Reasoning: Forms of Inquiry ina Therapeutic Practice. Philadelphia, Pa: FA Davis Co; 1994.

30Hagedorn R. Clinical decision making in familiar cases: a model ofthe process and implications for practice. Br J Occup Ther. 1996;59:217222.

31Crepeau EB. Achieving intersubjective understanding: examplesfrom an occupational therapy treatment session. Am J Occup Ther.1991;45:10161025.

32Greenhalgh T, Hurwitz B. Why study narrative? In: Greenhalgh T,Hurwitz B, eds. Narrative-Based Medicine: Dialogue and Discourse inClinical Practice. London, United Kingdom: BMJ Books; 1998:316.

33Habermas J. Theory of Communicative Action. Vol 1. Boston, Mass:Beacon Press; 1984.



19/19

34Kleinman A.The Illness Narratives: Suffering, Healing, and the HumanCondition. New York, NY: Basic Books; 1988.

35Mezirow J. Transformative Dimensions of Adult Learning. San Fran-cisco, Calif: Jossey-Bass Inc Publishers; 1991.

36Schon D.The Reflective Practitioner: How Professionals Think in Action.New York, NY: Basic Books; 1983.

37Patel VL, Arocha JF. Methods in the study of clinical reasoning.

In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions.2nd ed. Boston, Mass: Butterworth-Heinemann; 2000:78 91.

38 Merriam SB. Qualitative Research and Case Study Applications inEducation: A Qualitative Approach. San Francisco, Calif: Jossey-Bass IncPublishers; 1998.

39Yin R.Case Study Research: Design and Methods. 2nd ed. Newbury Park,Calif: Sage Publications; 1994.

40White M, Epston D. Narrative Means to Therapeutic Ends. New York,NY: WW Norton and Co; 1990.

41Borkan JM, Quirk M, Sullivan M. Finding meaning after the fall:injury narratives from elderly hip fracture patients. Soc Sci Med.1991;33:947957.

42May BJ, Dennis JK. Expert decision making in physical therapy: asurvey of practitioners. Phys Ther. 1991;71:190202.

43Christensen N. Clinical Pattern Recognition in Physiotherapists: A PilotStudy Investigating the Effect of Different Levels of Experience [unpublishedmasters thesis]. Adelaide, South Australia, Australia: University ofSouth Australia; 1993.

44Zvulun I.The Development and Preliminary Testing of an Assessment Toolfor Clinical Reasoning in Physiotherapy [unpublished masters thesis].Adelaide, South Australia, Australia: University of South Australia;1993.

45Rivett DA, Higgs J. Hypothesis generation in the clinical reasoningbehavior of manual therapists. Journal of Physical Therapy Education.1997;11(1):40 45.

46 Strauss A, Corbin J. Grounded theory methodology: an overview.In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research.London, United Kingdom: Sage Publications; 1994:273285.

47Grbich C.Qualitative Research in Health: An Introduction. Sydney, NewSouth Wales, Australia: Allen and Unwin; 1999.

48Morse J. Theory innocent or theory smart [editorial]? Qual HealthRes. 2002:12:295296.

49Kluzel A. Sampling in qualitative inquiry. In: Crabtree B, Miller W,eds. Doing Qualitative Research. 2nd ed. Newbury Park, Calif: SagePublications; 1994:33.

50Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed.London, United Kingdom: Sage Publications; 1990.

51 Hawthorne RK. Curriculum in the Making: Teacher Choice and theClassroom Experience. New York, NY: Teachers College Press; 1992.

52Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, Calif: SagePublications; 1985.

53Morse JM. Emerging from the data: the cognitive processes ofanalysis in qualitative inquiry. In: Morse JM, ed. Critical Issues inQualitative Research Methods. Newbury Park, Calif: Sage Publications;1994:23 43.

54Miles MB, Huberman AM. Qualitative Data Analysis. 2nd ed. Lon-don, United Kingdom: Sage Publications; 1994.

55Koch T. Establishing rigour in qualitative research: the decisiontrail.J Adv Nurs. 1994;19:976986.

56Geertz C. The Interpretation of Cultures. New York, NY: Basic Books;1973.

57Collins Dictionary of the English Language. 2nd ed. London, UnitedKingdom: Collins; 1986.

58Edwards I. Clinical reasoning in three different fields of physiother-apy: a qualitative study; The Australian Digitized Theses Program.2001. Available at: http://www.library.unisa.edu.au/adt-root/public/adt-SUSA-20030603-090552/index.html. Accessed October 31, 2003.

59Hudson Jones A. Narrative in medical ethics. In: Greenhalgh T,Hurwitz B, eds. Narrative-Based Medicine: Dialogue and Discourse inClinical Practice. London, United Kingdom: BMJ Books; 1998:217224.

60Code of Conduct. Melbourne, Victoria, Australia: Australian Physio-therapy Association; June 1999.

61Childress J. Narrative(s) versus norm(s): a misplaced debate inbioethics. In: Nelson HL, ed. Stories and Their Limits: NarrativeApproaches to Bioethics. New York, NY: Routledge; 1997:252271.

62Waddell G. The Back Pain Revolution. New York, NY: ChurchillLivingstone Inc; 1998.

63International Classification of Functioning, Disability and Health.Geneva, Switzerland: World Health Organization; 2001.

Documents

clinical strategies in physical therapy