Development of an Innovative Tool to Assess Student Physical Therapists’ Clinical Reasoning Competency

Abstract

BACKGROUND AND PURPOSEIn the recent decades, the role of physical therapists (PTs) has been changing with an ever-increasing autonomy,1 accountability,2,3 and public expectation of professional competency.4 Since clinical reasoning is a vital component of professional competency,5 the American Physical Therapy Association has specified clinical reasoning as an educational outcome for graduates of physical therapist education programs.6 The importance of clinical reasoning in physical therapist education demands discipline-specific assessment tools7 and a thorough assessment system that incorporates different types of assessments.8Miller9 proposed a pyramidal framework, which divides clinical assessment into 4 hierarchical levels-knows, knows how, shows how, and does-in a bottom-up sequence. Rethans et al10 redefined the last 2 levels and labeled them as competency and performance, respectively. Miller's9 pyramid with the modified definitions provides a theoretical framework to form a comprehensive system for assessing the clinical reasoning of student physical therapists (SPTs). Figure 1 illustrates the assessment system, including the definition and testing environment of each level. Paper-based examinations are means to assess cognitive knowledge11 and can be used to test students' clinical reasoning at the bottom 2 levels. The Physical Therapist Clinical Performance Instrument: version 200612 (PT CPI: version 2006), on the other hand, serves as a tool to assess students' clinical reasoning at the performance level. To date, no tool has been designed to assess the competency level-what an individual is capable of doing in a controlled representation of professional practice.10 The lack of competency assessment makes the assessment system incomplete.Standardized patients have been used in examinations to provide simulated clinical encounters,9 which is a requirement for testing competency.10 For students who do not perform well on standardized patient examinations, their underlying problems have been categorized into 3 types: technique, cognitive, and noncognitive, with clinical reasoning and knowledge deficits identified as the cognitive problems.13 Identifying students who struggle with standardized patient examinations due to deficits in clinical reasoning can be a challenge, because clinical reasoning is a nearly invisible process14 that is not easily accessible or assessable. Therefore, the invisibility issue of clinical reasoning needs to be addressed in order to make standardized patient examinations a more suitable testing environment to assess students' clinical reasoning competency. Qualitative researchers adopted a method when studying the mostly invisible clinical reasoning process.15-17 The method required the research participants to encounter with clinical cases and verbalize their thinking underpinning the encounter, either concurrently (during the encounter) or retrospectively (after the encounter). Ericsson and Simon18 supported the use of verbal reports, particularly the concurrent and immediate retrospective ones, as a valid source of information about cognitive processes. Thus, combining the think aloud method with a standardized patient examination is theoretically sound in making the mostly invisible clinical reasoning visible and accurately represented in a simulated testing environment. Despite the theoretical soundness, scarce evidence is available pertaining to the combination. Pintz19 developed a standardized patient examination for assessing nurse practitioner students' diagnostic reasoning. Each student was required to work with a standardized patient alone, with the performance videorecorded for grading. The researcher reported occasions that the standardized patient had to prompt the students to think aloud. However, there was no description that the standardized patients were trained to do so. The lack of training might have made the prompting inconsistent. …