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Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument
Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. (BEME)ORCID iD: 0000-0001-5356-916X
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 [en]
Assessment, Behaviour change, Clinical reasoning, Education, Functional behavioural analysis, Physiotherapy, Reliability, Scale development, Validity
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:mdh:diva-42931ISBN: 978-91-7485-426-8 (print)OAI: oai:DiVA.org:mdh-42931DiVA, id: diva2:1297040
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
List of papers
1. A clinical reasoning model focused on clients' behaviour change with reference to physiotherapists: Its multiphase development and validation
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
2. Development and initial evaluation of an instrument to assess physiotherapists' clinical reasoning focused on clients' behavior change
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
3. Criterion scores, construct validity and reliability of a web-based instrument to assess physiotherapists' clinical reasoning focused on behaviour change: 'Reasoning 4 Change'
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'
Show others...
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
4. Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist Students
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

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Elvén, Maria

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