Learning to communicate clinical reasoning in physiotherapy practice

Effective clinical reasoning and its communication are essential to health professional practice, especially in the current health care climate. Increasing litigation leading to legal requirements for comprehensive, relevant and appropriate information exchange between health professionals and patients (including their caregivers) and the drive for active consumer involvement are two key factors that underline the importance of clear communication and collaborative decision making. Health professionals are accountable for their decisions and service provision to various stakeholders, including patients, health sector managers, policy-makers and colleagues. An important aspect of this accountability is the ability to clearly articulate and justify management decisions. Considerable research across the health disciplines has investigated the nature of clinical reasoning and its relationship with knowledge and expertise. However, physiotherapy research literature to date has not specifically addressed the interaction between communication and clinical reasoning in practice, neither has it explored modes and patterns of learning that facilitate the acquisition of this complex skill. The purpose of this research was to contribute to the profession’s knowledge base a greater understanding of how experienced physiotherapists having learned to reason, then learn to communicate their clinical reasoning with patients and with novice physiotherapists. Informed by the interpretive paradigm, a hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants’ learning journeys were diverse, although certain factors and episodes of learning were common or similar. Participation with colleagues, peers and students, where the participants felt supported and guided in their learning, was a powerful way to learn to reason and to communicate reasoning. Experiential learning strategies, such as guidance, observation, discussion and feedback were found to be effective in enhancing learning of clinical reasoning and its communication. The cultural and environmental context created and supported by the practice community (which includes health professionals, patients and caregivers) was found to influence the participants’ learning of clinical reasoning and its communication. Participants reported various incidents that raised their awareness of their reasoning and communication abilities, such as teaching students on clinical placements, and informal discussions with peers about patients; these were linked with periods of steep learning of both abilities. Findings from this research present learning to reason and to communicate reasoning as journeys of professional socialisation that evolve through higher education and in the workplace. A key finding that supports this view is that clinical reasoning and its communication are embedded in the context of professional practice and therefore are best learned in this context of becoming, and developing as, a member of the profession. Communication of clinical reasoning was found to be both an inherent part of reasoning and an essential and complementary skill necessary for sound reasoning, that was embedded in the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined and should be learned concurrently. The learning and teaching of clinical reasoning and its communication should be synergistic and integrated; contextual, meaningful and reflexive

Changing representations of student achievement: the need for innovation

Transcripts and testamurs serve to confirm the award of a degree but offer limited information on what a student can actually do. This conceptual paper considers the problem of how graduate achievements are represented by universities in typically reductive and limited ways that do not enable student achievements and distinctiveness to be communicated to future employers, communities and students themselves. It argues that refinements to existing methods for the design and development of assessment are needed to encompass both university validated and contextualised credentials along with student-constructed portrayals of achievement and personas. Significant change is needed to assessment design, data capture and storage and the ways in which learning outcomes are tracked across a program and over time. Innovations in assessment representation should strengthen employer trust in the value of degrees, student trust in assessment processes and scaffold student agency in curating their employability narratives

Researching feedback dialogue: an interactional analysis approach

A variety of understandings of feedback exist in the literature, which can broadly be categorised as cognitivist information transmission and socio-constructivist. Understanding feedback as information transmission or ‘telling’ has until recently been dominant. However, a socio-constructivist perspective of feedback posits that feedback should be dialogic and help to develop students’ ability to monitor, evaluate and regulate their learning. This paper is positioned as part of the shift away from seeing feedback as input, to exploring feedback as a dialogical process focusing on effects, through presenting an innovative methodological approach to analysing feedback dialogues in situ. Interactional analysis adopts the premise that artefacts and technologies set up a social field, where understanding human–human and human–material activities and interactions is important. The paper suggests that this systematic approach to analysing dialogic feedback can enable insight into previously undocumented aspects of feedback, such as the interactional features that promote and sustain feedback dialogue. The paper discusses methodological issues in such analyses and implications for research on feedback

Examining the nature and effects of feedback dialogue

Research has conventionally viewed feedback from the point of view of the input, thus analysing only one side of the feedback relationship. More recently, there has be an increased interest in understanding feedback-as-talk. Feedback dialogue has been conceptualised as the dynamic interplay of three dimensions: the cognitive, the social-affective and the structural. We sought to explore the interactional features of each dimension and their intermediary effects on students. We analysed students’ feedback dialogue excerpts as cases using interactional analysis. Analysis involved iterative inductive and deductive coding and interpretation of feedback texts generated in an online course. The cognitive, social-affective and structural dimensions were interwoven within excerpts of feedback dialogue with effects on learners that extended beyond the immediate task (e.g. reframing of learners’ ideas, critical evaluation). The interactional features of each dimension include: cognitive (e.g. question asking, expressing oneself); social-affective (e.g. disclosure, expressing empathy); and structural (e.g. longitudinal opportunities for dialogue, invitational opportunities). The study provides evidence that strengthens the call for reconceptualising feedback as a dialogic and relational activity as well as supporting the view that dialogic feedback can be a key strategy for sustainable assessment

Translating evidence-based guidelines to improve feedback practices:the interACT case study

Background: There has been a substantial body of research examining feedback practices, yet the assessment and feedback landscape in higher education is described as ‘stubbornly resistant to change’. The aim of this paper is to present a case study demonstrating how an entire programme’s assessment and feedback practices were re-engineered and evaluated in line with evidence from the literature in the interACT (Interaction and Collaboration via Technology) project.Methods: Informed by action research the project conducted two cycles of planning, action, evaluation and reflection. Four key pedagogical principles informed the re-design of the assessment and feedback practices. Evaluation activities included document analysis, interviews with staff (n = 10) and students (n = 7), and student questionnaires (n = 54). Descriptive statistics were used to analyse the questionnaire data. Framework thematic analysis was used to develop themes across the interview data.Results: InterACT was reported by students and staff to promote self-evaluation, engagement with feedback and feedback dialogue. Streamlining the process after the first cycle of action research was crucial for improving engagement of students and staff. The interACT process of promoting self-evaluation, reflection on feedback, feedback dialogue and longitudinal perspectives of feedback has clear benefits and should be transferable to other contexts.Conclusions: InterACT has involved comprehensive re-engineering of the assessment and feedback processes using educational principles to guide the design taking into account stakeholder perspectives. These principles and the strategies to enact them should be transferable to other contexts

Developing a national dental education research strategy:priorities, barriers and enablers

Objectives: This study aimed to identify national dental education research (DER) priorities for the next 3-5 years and to identify barriers and enablers to DER. Setting: Scotland Participants: In this two-stage online questionnaire study we collected data with multiple dental professions (e.g. dentistry, dental nursing, dental hygiene) and stakeholder groups (e.g. learners, clinicians, educators, managers, researchers, academics). Eighty-five participants completed the Stage 1 qualitative questionnaire and 649 participants the Stage 2 quantitative questionnaire. Results: Eight themes were identified at Stage 1. Of the 24 DER priorities identified, the top three were: role of assessments in identifying competence; undergraduate curriculum prepares for practice; and promoting teamwork. Following exploratory factor analysis, the 24 items loaded onto four factors: teamwork and professionalism, measuring and enhancing performance, dental workforce issues, and curriculum integration and innovation. Barriers and enablers existed at multiple levels: individual, interpersonal, institutional structures and cultures, and technology. Conclusion: This priority setting exercise provides a necessary first step to developing a national DER strategy capturing multiple perspectives. Promoting DER requires improved resourcing alongside efforts to overcome peer stigma and lack of valuing and motivation

Researching feedback dialogue: an interactional analysis approach

A variety of understandings of feedback exist in the literature, which can broadly be categorised as cognitivist information transmission and socio-constructivist. Understanding feedback as information transmission or ‘telling’ has until recently been dominant. However, a socio-constructivist perspective of feedback posits that feedback should be dialogic and help to develop students’ ability to monitor, evaluate and regulate their learning. This paper is positioned as part of the shift away from seeing feedback as input, to exploring feedback as a dialogical process focusing on effects, through presenting an innovative methodological approach to analysing feedback dialogues in situ. Interactional analysis adopts the premise that artefacts and technologies set up a social field, where understanding human–human and human–material activities and interactions is important. The paper suggests that this systematic approach to analysing dialogic feedback can enable insight into previously undocumented aspects of feedback, such as the interactional features that promote and sustain feedback dialogue. The paper discusses methodological issues in such analyses and implications for research on feedback

Using hermeneutic phenomenology to investigate how experienced practitioners learn to communicate clinical reasoning

This paper is primarily targeted at doctoral students and other researchers considering using hermeneutic phenomenology as a research strategy. We present interpretive paradigm research designed to investigate how experienced practitioners learn to communicate their clinical reasoning in professional practice. Twelve experienced physiotherapy practitioners participated in this research. Using hermeneutic phenomenology enabled access to a phenomenon that is often subconscious and provided a means of interpreting participants’ experiences of personal learning journeys. Within the philosophy underpinning hermeneutic phenomenology, researchers need to design a research strategy that flows directly from the research question and goals of the research project. This paper explores such a strategy

Hero, survivor or stuck: a narrative analysis of student constructions of persistence after failure

Academic failure is commonplace in higher education. Some students persist and go on to complete their courses. However, some do not, and this can create problems for themselves and the institutions in which they are enrolled. If we could understand students’ lived experiences of academic failure and persistence, it may be possible to design strategies that assist others to more effectively navigate the demands of higher education. A narrative inquiry was undertaken with students who failed and persisted with their course to understand how identities and agency influenced persistence following failure. Using figured worlds theory and narrative analysis, three patterns of persistence were identified characterised as a hero’s journey, surviving failure and stuck in the system. The positions students adopted in relation to other actors within their narratives ranged from active to passive, highlighting different agentic responses of students. Implications for supporting students to recover from failure are discussed

Measuring what matters: the positioning of students in feedback processes within national student satisfaction surveys

The increasing prominence of neoliberal agendas in international higher education has led to greater weight being ascribed to student satisfaction, and the national surveys through which students evaluate courses of study. In this article, we focus on the evaluation of feedback processes. Rather than the transmission of information from teacher to student, greater recognition of the fundamental role of the learner in seeking, generating, and using feedback information is evident in recent international literature. Through an analysis of the framing of survey items from 10 national student satisfaction surveys, we seek to question what conceptions or models of feedback are conveyed through survey items, and how such framing might shape perceptions and practice. Primarily, the surveys promote an outdated view of feedback as information transmitted from teacher to student in a timely and specific manner, largely ignoring the role of the student in learning through feedback processes. Widespread and meaningful change in the ways in which feedback is represented in research, policy, and practice requires a critical review of the positioning of students in artefacts such as evaluation surveys. We conclude with recommendations for practice by proposing amended survey items that are more consistent with contemporary theoretical conceptions of feedback