Clinical Reasoning: Development of a Grading Rubric for Student Assessment

Abstract

BACKGROUND AND PURPOSEIf faculty members want to better understand student learning and the development of student reasoning abilities, avenues to gain insight into student thinking are needed. Sound teaching and learning strategies should be studied and shared to improve this educational process. In order to improve our ability as teachers, we must engage in inquiry into the process of teaching along with the evidence of student learning, the outcome of teaching.1 As described by Ernest Boyer, an inquiry driven approach consistent with the scholarship of teaching may best help us understand critical issues in the assessment of student learning.2Scholarship of teaching and learning projects allow educators to evaluate teaching strategies by using assessment of student learning as a primary source of evidence.2,3 To understand the development of a complicated ability such as clinical reasoning, one must investigate the evidence of student learning, as well as the teaching strategies linked to it. Shulman describes it well, saying:To prompt learning, you've got to begin with the processes-the inside from the inside out. The first influence on new learning is not what teachers do pedagogically but the learning that's already inside the learner.Bps36'Clinical reasoning is a multifactorial and complex phenomenon.4 Research in the health professions identifies clinical reasoning used in clinical practice as a collaborative and reflective process that involves contentspecific knowledge, engagement of the patient and family in understanding the clinical problem, and incorporation of critical contextual factors. All of these factors lead to deliberative decision making and sound clinical judgment.4,5 As defined by Christensen et al, clinical reasoning is the thinking and decision making process used for examination and patient management.6 The American Physical Therapy Association (APTA) recognizes the importance of clinical reasoning as a required practice skill.7 The Commission on Accreditation of Physical Therapy Education (CAPTE) requires that all physical therapist (PT) education programs develop and assess clinical reasoning skills as a professional practice expectation.8 Students must be able to utilize clinical reasoning to enhance patient care and minimize errors in practice.A nonnegotiable component or foundation for the development of clinical reasoning is the students' ability to engage in self-monitoring and critical self-reflection. The ability to monitor self, stop the action, bring different frames of perspective to the situation, see the context of the problem, and grapple with the uncertainty of the situation are skills that depend on self-monitoring and critical self-reflection.9'12 Learners are engaged in a life-long process of honing their skills to be attentive, mindful, and nonjudgmental. These skills go well beyond the traditional notions of analytical thinking and looking for the right answer or definitive piece of evidence that are far too often seen as the most important aspects of critical thinking.1'11,13Due to the multidimensional nature of clinical reasoning, assessment of this skill is challenging for educators and clinical instructors. There are few standardized tools available to evaluate student clinical reasoning abilities in physical therapy. Most of the existing assessment tools were developed for use in other health care professions and assess critical thinking rather than clinical reasoning.14 Some of these tools include the Health Science Reasoning Test and the California Critical Thinking Skills Test.15 While critical thinking is an important skill for all students, we argue here that clinical reasoning is a more robust concept, as it not only focuses on the mental processes, but also includes the connections between these processes and the behaviors that are shared between the patient, practitioner, and the environment.16The following tools and teaching strategies have been used with some success to assess clinical reasoning: the script concordance test, concept mapping, thinking aloud, quantitative standardized tests, reflection, interviews, and focus groups. …