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

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

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

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

"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

BackgroundMuch of a General Practitioner&rsquo;s (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees&rsquo; clinical and educational experiences of managing people presenting with MUS.MethodA mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.ResultsEighty questionnaires out of 120 (67 %) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.ConclusionManaging MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.<br /

Persisting students' explanations of and emotional responses to academic failure

Academic failure is an important and personal event in the lives of university students, and the ways they make sense of experiences of failure matters for their persistence and future success. Academic failure contributes to attrition, yet the extent of this contribution and precipitating factors of failure are not well understood. To illuminate this world-wide problem, we analysed institutional data at a large, comprehensive Australian university and surveyed 186 undergraduate students who had failed at least one unit of study in 2016, but were still enrolled in 2017. Academic failure increased the likelihood of course attrition by 4.2 times. The students who failed and persisted attributed academic failure to a confluence of dispositional, situational, and institutional factors. There was a compounded effect of academic failure on already-vulnerable students resulting in strong negative emotions. Viewing persistence as an interaction between individuals and their sociocultural milieu opens up different avenues for research and considerations for support

Persisting students\u27 explanations of and emotional responses to academic failure

Academic failure is an important and personal event in the lives of university students, and the ways they make sense of experiences of failure matters for their persistence and future success. Academic failure contributes to attrition, yet the extent of this contribution and precipitating factors of failure are not well understood. To illuminate this world-wide problem, we analysed institutional data at a large, comprehensive Australian university and surveyed 186 undergraduate students who had failed at least one unit of study in 2016, but were still enrolled in 2017. Academic failure increased the likelihood of course attrition by 4.2 times. The students who failed and persisted attributed academic failure to a confluence of dispositional, situational, and institutional factors. There was a compounded effect of academic failure on already-vulnerable students resulting in strong negative emotions. Viewing persistence as an interaction between individuals and their sociocultural milieu opens up different avenues for research and considerations for support

Data as symptom: Doctors’ responses to patient-provided data in general practice

People are increasingly able to generate their own health data through new technologies such as wearables and online symptom checkers. However, generating data is one thing, interpreting them another. General practitioners (GPs) are likely to be the first to help with interpretations. Policymakers in the European Union are investing heavily in infrastructures to provide GPs access to patient measurements. But there may be a disconnect between policy ambitions and the everyday practices of GPs. To investigate this, we conducted semi-structured interviews with 23 Danish GPs. According to the GPs, patients relatively rarely bring data to them. GPs mostly remember three types of patient-generated data that patients bring to them for interpretation: heart and sleep measurements from wearables and results from online symptom checkers. However, they also spoke extensively about data work with patient queries concerning measurements from the GPs’ own online Patient Reported Outcome system and online access to laboratory results. We juxtapose GP reflections on these five data types and between policy ambitions and everyday practices. These data require substantial recontextualization work before the GPs ascribe them evidential value and act on them. Even when they perceived as actionable, patient-provided data are not approached as measurements, as suggested by policy frameworks. Rather, GPs treat them as analogous to symptoms—that is to say, GPs treat patient-provided data as subjective evidence rather than authoritative measures. Drawing on Science and Technology Studies (STS) literature,we suggest that GPs must be part of the conversation with policy makers and digital entrepreneurs around when and how to integrate patient-generated data into healthcare infrastructures

Creating an agenda for developing students' evaluative judgement

© 2018 selection and editorial matter, David Boud, Rola Ajjawi, Phillip Dawson and Joanna Tai. What practical directions can be taken to develop students’ evaluative judgement? Such processes involve more than adding activities into the curriculum. They require repositioning how students become graduates, how courses are structured, and what constitutes progression from one level of sophistication to another. This chapter examines the role of assessment in supporting the development of evaluative judgement; how it can contribute to students judging their own work and that of others; and how peers, educators and others can contribute to this process