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Elvén, M. (2019). Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument. (Doctoral dissertation). Västerås: Mälardalen University
Open this publication in new window or tab >>Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

With the recognition of the impact of lifestyle behaviours on health and the evidence of incorporating behavioural considerations in physiotherapy, there is a need to advance the clinical reasoning of physiotherapists. Clinical reasoning encompasses the thinking and decision-making processes guiding client management and is a core competency of physiotherapists. Enabling clinical reasoning advancements requires investigations in practice and education, which in turn require robust assessments. The overall aim of this thesis was to develop and evaluate an instrument to study physiotherapy students’ clinical reasoning focused on clients’ activity-related behaviour and behaviour change.

In study I, a conceptual model was developed based on exploration of existing research, theory and views of physiotherapists and students. The data resulted in the clinical reasoning model focused on clients’ behaviour change with reference to physiotherapists (CRBC-PT). Studies II and III included instrument development and evaluation in four phases. Phase 1 included determination of the instrument structure and item generation based on the CRBC-PT model, evidence in clinical reasoning assessment and existing measures. Phase 2 included cognitive interviews with students to assess item understanding and resulted in revisions of item problems and approval of feasibility. Phase 3 included a Delphi study with physiotherapists with expertise in behavioural medicine to evaluate item relevance. The findings demonstrated a high level of consensus regarding content relevance. The final version of the Reasoning 4 Change (R4C) instrument included four domains, namely, Physiotherapist, Input from client, Functional behavioural analysis, and Strategies for behaviour change. In phase 4, the reliability and validity of the instrument were evaluated. Physiotherapists with expertise in behavioural medicine and students responded to the web-based R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists. The analyses showed excellent inter-rater reliability, satisfactory construct validity, internal consistency and test-retest reliability. In study IV, final-semester students (n=151) from all physiotherapy programmes in Sweden completed the R4C instrument. Hierarchical multiple regression analyses were conducted with three dependent variables, namely, input from client, functional behavioural analysis, and strategies for behaviour change. All included independent variables explained 37% of the variance in input from client. Cognitive and metacognitive skills explained 22%, attitudes 15% and curriculum with behavioural medicine competencies 3%. Only the variable curriculum with behavioural medicine competencies explained the variance in functional behavioural analysis (4%) and strategies for behaviour change (5%).

In conclusion, the in-depth description of clinical reasoning focused on clients’ behaviour change may contribute to expanded understanding of the complexity and multidimensionality in reasoning processes that incorporate factors related to human behaviours, analyses of what factors motivate or hinder behaviours, and interventions to support behaviour change. Such knowledge is valuable for the teaching of and learning clinical reasoning. The R4C instrument helps fill the need for well-tested instruments and can support investigations and evaluations in physiotherapy education and research. To develop students’ clinical reasoning competence, cognitive and metacognitive skills, positive attitudes and the incorporation of behavioural medicine competencies into physiotherapy curricula should be targeted. Further attention to complex reasoning, including analysis and intervention, is warranted.

Place, publisher, year, edition, pages
Västerås: Mälardalen University, 2019. p. 101
Series
Mälardalen University Press Dissertations, ISSN 1651-4238 ; 289
Keywords
Assessment, Behaviour change, Clinical reasoning, Education, Functional behavioural analysis, Physiotherapy, Reliability, Scale development, Validity
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-42931 (URN)978-91-7485-426-8 (ISBN)
Public defence
2019-05-24, Beta, Mälardalens högskola, Västerås, 09:30 (Swedish)
Opponent
Supervisors
Available from: 2019-03-19 Created: 2019-03-18 Last updated: 2019-11-12Bibliographically approved
Elvén, M., Hochwälder, J., Dean, E. & Söderlund, A. (2019). Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist Students. Physical Therapy, 99(8), 964-976
Open this publication in new window or tab >>Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist Students
2019 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 99, no 8, p. 964-976Article in journal (Refereed) Published
Abstract [en]

Although physical therapist students must be well prepared to integrate biopsychosocial and behavioral perspectives into their clinical reasoning, there is a lack of knowledge regarding factors that influence such competence. This study explored the associations among the independent variables-knowledge, cognition, metacognition, psychological factors, contextual factors, and curriculum orientation vis-a-vis behavioral medicine competencies-and the dependent variables-outcomes of input from client (IC), functional behavioral analysis (FBA), and strategies for behavior change (SBC) as levels in physical therapist students' clinical reasoning processes. This study used an exploratory cross-sectional design. The Reasoning 4 Change instrument was completed by 151 final-semester physical therapist students. Hierarchical multiple regression analyses for IC, FBA, and SBC were conducted. In the first step, curriculum orientation was inserted into the model; in the second step, self-rated knowledge, cognition, and metacognition; and in the third step, psychological factors. All independent variables except contextual factors explained 37% of the variance in the outcome of IC. Curriculum orientation explained 3%, cognitive and metacognitive factors an additional 22%, and attitudes another 15%. Variance in the outcomes of FBA and SBC were explained by curriculum orientation only (FBA change in R-2=0.04; SBC change in R-2=0.05). Higher scores of the dependent variables were associated with a curriculum having behavioral medicine competencies. The limitations of this study are that it was cross-sectional. Cognitive and metacognitive capabilities and skills and positive attitudes are important predictors of physical therapist students' clinical reasoning focused on behavior change at the IC level. Curricula with behavioral medicine competencies are associated with positive outcomes at all clinical reasoning levels.

National Category
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-42932 (URN)10.1093/ptj/pzz044 (DOI)000482424200003 ()30869789 (PubMedID)2-s2.0-85070756500 (Scopus ID)
Available from: 2019-03-18 Created: 2019-03-18 Last updated: 2019-11-12Bibliographically approved
Elvén, M., Hochwälder, J., Dean, E., Hällman, O. & Söderlund, A. (2018). Criterion scores, construct validity and reliability of a web-based instrument to assess physiotherapists' clinical reasoning focused on behaviour change: 'Reasoning 4 Change'. AIMS PUBLIC HEALTH, 5(3), 235-259
Open this publication in new window or tab >>Criterion scores, construct validity and reliability of a web-based instrument to assess physiotherapists' clinical reasoning focused on behaviour change: 'Reasoning 4 Change'
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2018 (English)In: AIMS PUBLIC HEALTH, ISSN 2327-8994, Vol. 5, no 3, p. 235-259Article in journal (Refereed) Published
Abstract [en]

Background and aim: 'Reasoning 4 Change' (R4C) is a newly developed instrument, including four domains (D1-D4), to assess clinical practitioners' and students' clinical reasoning with a focus on clients' behaviour change in a physiotherapy context. To establish its use in education and research, its psychometric properties needed to be evaluated. The aim of the study was to generate criterion scores and evaluate the reliability and construct validity of a web-based version of the R4C instrument. Methods: Fourteen physiotherapy experts and 39 final-year physiotherapy students completed the R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Twelve experts and 17 students completed the R4C instrument on a second occasion. The R4C instrument was evaluated with regard to: internal consistency (five subscales of D1); test-retest reliability (D1-D4); inter-rater reliability (D2-D4); and construct validity in terms of convergent validity (D1.4, D2, D4). Criterion scores were generated based on the experts' responses to identify the scores of qualified practitioners' clinical reasoning abilities. Results: For the expert and student samples, the analyses demonstrated satisfactory internal consistency (alpha range: 0.67-0.91), satisfactory test-retest reliability (ICC range: 0.46-0.94) except for D3 for the experts and D4 for the students. The inter-rater reliability demonstrated excellent agreement within the expert group (ICC range: 0.94-1.0). The correlations between the R4C instrument and PABS-PT (r range: 0.06-0.76) supported acceptable construct validity. Conclusions: The web-based R4C instrument shows satisfactory psychometric properties and could be useful in education and research. The use of the instrument may contribute to a deeper understanding of physiotherapists' and students' clinical reasoning, valuable for curriculum development and improvements of competencies in clinical reasoning related to clients' behavioural change.

Place, publisher, year, edition, pages
AMER INST MATHEMATICAL SCIENCES-AIMS, 2018
Keywords
assessment, behaviour change, clinical reasoning, education, physiotherapy, psychometrics, reliability, validity, web application
National Category
Health Sciences
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-40738 (URN)10.3934/publichealth.2018.3.235 (DOI)000442478900004 ()30280115 (PubMedID)
Available from: 2018-09-06 Created: 2018-09-06 Last updated: 2019-11-12Bibliographically approved
Elvén, M., Hochwälder, J., Dean, E. & Söderlund, A. (2018). Development and initial evaluation of an instrument to assess physiotherapists' clinical reasoning focused on clients' behavior change. Physiotherapy Theory and Practice, 34(5), 367-383
Open this publication in new window or tab >>Development and initial evaluation of an instrument to assess physiotherapists' clinical reasoning focused on clients' behavior change
2018 (English)In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 34, no 5, p. 367-383Article in journal (Refereed) Published
Abstract [en]

Background and Aim: A systematically developed and evaluated instrument is needed to support investigations of physiotherapists' clinical reasoning integrated with the process of clients' behavior change. This study's aim was to develop an instrument to assess physiotherapy students' and physiotherapists' clinical reasoning focused on clients' activity-related behavior and behavior change, and initiate its evaluation, including feasibility and content validity. Methods: The study was conducted in three phases: 1) determination of instrument structure and item generation, based on a model, guidelines for assessing clinical reasoning, and existing measures; 2) cognitive interviews with five physiotherapy students to evaluate item understanding and feasibility; and 3) a Delphi process with 18 experts to evaluate content relevance. Results: Phase 1 resulted in an instrument with four domains: Physiotherapist; Input from client; Functional behavioral analysis; and Strategies for behavior change. The instrument consists of case scenarios followed by items in which key features are identified, prioritized, or interpreted. Phase 2 resulted in revisions of problems and approval of feasibility. Phase 3 demonstrated high level of consensus regarding the instrument's content relevance. Conclusions: This feasible and content-validated instrument shows potential for use in investigations of physiotherapy students' and physiotherapists' clinical reasoning, however continued development and testing are needed.

Keywords
Behavior change, clinical reasoning, instrument development, physiotherapy, validity
National Category
Health Sciences
Identifiers
urn:nbn:se:mdh:diva-42887 (URN)10.1080/09593985.2017.1419521 (DOI)000425789400004 ()29405848 (PubMedID)2-s2.0-85041579507 (Scopus ID)
Available from: 2019-03-11 Created: 2019-03-11 Last updated: 2019-11-12Bibliographically approved
Sandborgh, M., Elvén, M., von Heideken Wågert, P., Snöljung, Å. & Söderlund, A. (2018). IMPLEMENTATION OF BEHAVIORAL MEDICINE IN A PHYSIOTHERAPY UNDERGRADUATE CURRICULUM STUDENT EVALUATIONS. International Journal of Behavioral Medicine, 25, S64-S65
Open this publication in new window or tab >>IMPLEMENTATION OF BEHAVIORAL MEDICINE IN A PHYSIOTHERAPY UNDERGRADUATE CURRICULUM STUDENT EVALUATIONS
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2018 (English)In: International Journal of Behavioral Medicine, ISSN 1070-5503, E-ISSN 1532-7558, Vol. 25, p. S64-S65Article in journal, Meeting abstract (Other academic) Published
Place, publisher, year, edition, pages
SPRINGER, 2018
National Category
Physiotherapy Psychology
Identifiers
urn:nbn:se:mdh:diva-41224 (URN)000446532700205 ()
Available from: 2018-10-25 Created: 2018-10-25 Last updated: 2019-11-11
Elvén, M., Hochwälder, J., Dean, E. & Söderlund, A. (2018). Predictors of clinical reasoning focused on clients’ behavior change among physical therapy students. In: Dyer, Joseph-Omer (Ed.), Raisonnement Clinique 2018: Textes del la 4e Conférence Internationale de Montréal sur le Raisonnment Clinique.. Paper presented at 4th Montréal International Conference on Clinical Reasoning 2018 Montréal, Canada..
Open this publication in new window or tab >>Predictors of clinical reasoning focused on clients’ behavior change among physical therapy students
2018 (English)In: Raisonnement Clinique 2018: Textes del la 4e Conférence Internationale de Montréal sur le Raisonnment Clinique. / [ed] Dyer, Joseph-Omer, 2018Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

Although physical therapy students need to be well prepared to integrate strategies to effect health-related behavior change into their clinical reasoning, educators lack knowledge regarding which factors contribute to such competence. This study’s aim was to investigate the degree to which knowledge, cognitive, psychological and contextual factors as well as curriculum orientation influences students’ clinical reasoning focused on behavior change.

151 physical therapy students in the final semester completed the web-based Reasoning 4 Change instrument (1). 61 students attended a physical therapy education program with a behavioral medicine approach. Hierarchical multiple regression analysis was used to investigate the degree to which curriculum orientation, self-rated knowledge, cognition, metacognition, attitudes, self-efficacy and contextual factors influence three outcomes of the clinical reasoning process, i.e., Input from Client, Functional Behavioral Analysis (FBA) and Strategies for Behavior Change (SBC).

37% of the total variance in Input from Client was explained by all variables (p<.001), except contextual factors. Cognitive and metacognitive factors and attitudes were most important. Attending a physical therapy program with a behavioral medicine curriculum orientation was the only variable in the model that explained FBA (adjusted R2=.04;p<.05) and SBC (adjusted R2=.04;p<.01).

National Category
Health Sciences
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-41533 (URN)978-2-89799-017-6 (ISBN)
Conference
4th Montréal International Conference on Clinical Reasoning 2018 Montréal, Canada.
Available from: 2018-12-11 Created: 2018-12-11 Last updated: 2019-11-11
Elvén, M. & Dean, E. (2017). Factors influencing physical therapists' clinical reasoning: qualitative systematic review and meta-synthesis. Physical Therapy Reviews, 22(1-2), 60-75
Open this publication in new window or tab >>Factors influencing physical therapists' clinical reasoning: qualitative systematic review and meta-synthesis
2017 (English)In: Physical Therapy Reviews, ISSN 1083-3196, E-ISSN 1743-288X, Vol. 22, no 1-2, p. 60-75Article in journal (Refereed) Published
Abstract [en]

Background: The capacity of physical therapists to reason effectively in patient management is essential to maximizing outcomes. Although conceptual frameworks of clinical reasoning exist, their theoretical foundations are insufficiently validated to establish those factors that are paramount in guiding physical therapists' clinical reasoning. Studies on how physical therapists clinically reason constitute important means of identifying constructs of such reasoning. Objective: This systematic review aimed to synthesize and interpret the findings of qualitative studies designed to examine factors that are inherent in physical therapists' clinical reasoning with respect to their knowledge, experiences, and practices. Methods: Searches of studies were carried out in four databases, gray literature, and reference lists. Two reviewers independently assessed methodological quality of the studies using the Critical Appraisal Skills Program (CASP) and performed the analysis: extraction and comparative appraisal of findings, identification of themes, reciprocal translation synthesis, and identification of categories and subcategories. Results: Ten studies were included. Four themes of factors influencing physical therapists' clinical reasoning emerged, namely, Physical therapist as a source, Patient as a source, Elements of the reasoning process, and Context. Conclusions: The identified themes validated some constructs underlying existing clinical reasoning frameworks. Most influencing factors were related to the physical therapist, which highlights opportunities to improve effective reasoning at this level. The notion that this process is recurrent, multifaceted, and contextual lends itself to changing in accordance with the needs of the patient, consistent with a biopsychosocial perspective. How clinicians weigh biomedical and psychosocial elements in their reasoning however warrants further study.

National Category
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-36159 (URN)10.1080/10833196.2017.1289647 (DOI)000404937300008 ()2-s2.0-85044041868 (Scopus ID)
Available from: 2017-07-27 Created: 2017-07-27 Last updated: 2019-11-11
Elvén, M. (2017). Reflections on qualitative meta-synthesis studies: 'getting the search strategy right'. Physical Therapy Reviews, 22(5-6), 219-220
Open this publication in new window or tab >>Reflections on qualitative meta-synthesis studies: 'getting the search strategy right'
2017 (English)In: Physical Therapy Reviews, ISSN 1083-3196, E-ISSN 1743-288X, Vol. 22, no 5-6, p. 219-220Article in journal, Editorial material (Other academic) Published
Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2017
National Category
Health Sciences
Identifiers
urn:nbn:se:mdh:diva-38676 (URN)10.1080/10833196.2017.1386265 (DOI)000423957800001 ()2-s2.0-85044091037 (Scopus ID)
Available from: 2018-02-16 Created: 2018-02-16 Last updated: 2019-11-11
Elvén, M., Hochwälder, J., Dean, E. & Söderlund, A. (2016). An innovative instrument to assess physiotherapists’ clinical reasoning focused on clients’ behaviour change: Its development and validation.. Paper presented at The 4th European Congress of the European Region of the World Confederation of Physical Therapy (ER-WCPT). Liverpool, UK, 11-12 November 2016. Physiotherapy, 102(s1), e155-e155
Open this publication in new window or tab >>An innovative instrument to assess physiotherapists’ clinical reasoning focused on clients’ behaviour change: Its development and validation.
2016 (English)In: Physiotherapy, ISSN 0031-9406, E-ISSN 1873-1465, Vol. 102, no s1, p. e155-e155Article in journal, Meeting abstract (Refereed) Published
National Category
Health Sciences
Research subject
Care Sciences
Identifiers
urn:nbn:se:mdh:diva-36292 (URN)10.1016/j.physio.2016.10.181 (DOI)
Conference
The 4th European Congress of the European Region of the World Confederation of Physical Therapy (ER-WCPT). Liverpool, UK, 11-12 November 2016
Available from: 2017-08-31 Created: 2017-08-31 Last updated: 2019-11-11
Elvén, M., Hochwälder, J., Dean, E. & Söderlund, A. (2015). A clinical reasoning model focused on clients' behaviour change with reference to physiotherapists: Its multiphase development and validation. Physiotherapy Theory and Practice, 31(4), 231-243
Open this publication in new window or tab >>A clinical reasoning model focused on clients' behaviour change with reference to physiotherapists: Its multiphase development and validation
2015 (English)In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 31, no 4, p. 231-243Article in journal (Refereed) Published
Abstract [en]

Background and purpose: A biopsychosocial approach and behaviour change strategies have long been proposed to serve as a basis for addressing current multifaceted health problems. This emphasis has implications for clinical reasoning of health professionals. This study's aim was to develop and validate a conceptual model to guide physiotherapists' clinical reasoning focused on clients' behaviour change. Methods: Phase 1 consisted of the exploration of existing research and the research team's experiences and knowledge. Phases 2a and 2b consisted of validation and refinement of the model based on input from physiotherapy students in two focus groups (n=5 per group) and from experts in behavioural medicine (n=9). Results: Phase 1 generated theoretical and evidence bases for the first version of a model. Phases 2a and 2b established the validity and value of the model. The final model described clinical reasoning focused on clients' behaviour change as a cognitive, reflective, collaborative and iterative process with multiple interrelated levels that included input from the client and physiotherapist, a functional behavioural analysis of the activity-related target behaviour and the selection of strategies for behaviour change. Conclusions: This unique model, theory- and evidence-informed, has been developed to help physiotherapists to apply clinical reasoning systematically in the process of behaviour change with their clients.

National Category
Health Sciences Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-42886 (URN)10.3109/09593985.2014.994250 (DOI)000353919600001 ()25533133 (PubMedID)2-s2.0-84928895635 (Scopus ID)
Available from: 2019-03-11 Created: 2019-03-11 Last updated: 2019-11-12Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-5356-916X

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