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  • 1.
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument2019Doctoral 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.

  • 2.
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Reflections on qualitative meta-synthesis studies: 'getting the search strategy right'2017In: Physical Therapy Reviews, ISSN 1083-3196, E-ISSN 1743-288X, Vol. 22, no 5-6, p. 219-220Article in journal (Other academic)
  • 3.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    Univ British Columbia, Canada.
    Factors influencing physical therapists' clinical reasoning: qualitative systematic review and meta-synthesis2017In: Physical Therapy Reviews, ISSN 1083-3196, E-ISSN 1743-288X, Vol. 22, no 1-2, p. 60-75Article in journal (Refereed)
    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.

  • 4.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Factors influencing physiotherapists' clinical reasoning: A meta-synthesis.2015In: Physiotherapy 2015, Stockholm, Sweden., 2015Conference paper (Refereed)
  • 5.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Factors influencing physiotherapists' clinical reasoning: a meta-synthesis2015In: Physiotherapy, ISSN 0031-9406, E-ISSN 1873-1465, Vol. 101, p. e360-e361Article in journal (Refereed)
  • 6.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Business, Society and Engineering. Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elisabeth
    Department of Physical Therapy, Faculty ofMedicine, University of British Columbia, Vancouver, BC, Canada.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    A clinical reasoning model focused on clients' behaviour change with reference to physiotherapists: Its multiphase development and validation2015In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 31, no 4, p. 231-243Article in journal (Refereed)
    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.

  • 7.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Business, Society and Engineering. Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elisabeth
    Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Development and initial evaluation of an instrument to assess physiotherapists' clinical reasoning focused on clients' behavior change2018In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 34, no 5, p. 367-383Article in journal (Refereed)
    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.

  • 8.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Dean, Elizabeth
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Dept Phys Therapy, Vancouver, BC, Canada..
    Hällman, Olle
    Uppsala Univ, Dept Informat Technol, Uppsala, Sweden..
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Criterion scores, construct validity and reliability of a web-based instrument to assess physiotherapists' clinical reasoning focused on behaviour change: 'Reasoning 4 Change'2018In: AIMS PUBLIC HEALTH, ISSN 2327-8994, Vol. 5, no 3, p. 235-259Article in journal (Refereed)
    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.

  • 9.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    A clinical reasoning model focused on clients’ behaviour change with reference to physiotherapists: Its multiphase development and validation2014In: Abstract book. The International Conference on Health and Social Welfare and Coproduction. Mälardalen University, Eskilstuna, Sweden. 9-10 sept 2014, 2014Conference paper (Refereed)
  • 10.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    An innovative instrument to assess physiotherapists’ clinical reasoning focused on clients’ behaviour change: Its development and validation.2016In: Physiotherapy, ISSN 0031-9406, E-ISSN 1873-1465, Vol. 102, no s1, p. e155-e155Article in journal (Refereed)
  • 11.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Development of a model of Clinical Reasoning with focus on patients’ Activity-related Behaviour and Behaviour change.2013In: Abstrakt bok. Sjukgymnastdagarna 2-4 oktober 2013, 2013, p. 110-111Conference paper (Refereed)
  • 12.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Development of a tool for assessing physiotherapy students’ clinical reasoning with focus on patients’ behavioural change2013In: Nordic Advances in Health Care Sciences Research. November 13-14 2013 in Lund. Abstract book, 2013, p. 13-13Conference paper (Refereed)
  • 13.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Predictors of clinical reasoning focused on clients’ behavior change among physical therapy students2018In: Raisonnement Clinique 2018: Textes del la 4e Conférence Internationale de Montréal sur le Raisonnment Clinique. / [ed] Dyer, Joseph-Omer, 2018Conference paper (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).

  • 14.
    Elvén, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Hochwälder, Jacek
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    University of British Columbia, Canada .
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare.
    Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist StudentsIn: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724Article in journal (Refereed)
  • 15.
    Fritz, Johanna
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Moberg, Johan
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Från klinikbesök till klinikhandledning: Om verksamhetsförlagd utbildning i fysioterapeutprogrammet vid Mälardalens Högskola2015Report (Other academic)
  • 16.
    Rahme, Hans
    et al.
    University Hospital, Uppsala, Sweden.
    Vikerfors, Ola
    Central Hospital, Västerås, Sweden.
    Ludvigsson, Lena
    Central Hospital, Västerås, Sweden.
    Elvén, Maria
    Central Hospital, Västerås, Sweden.
    Michaëlsson, K
    University Hospital, Uppsala, Sweden.
    Loss of external rotation after opern Bankart repair: an important prognostic factor for patient satisfaction2010In: Knee Surgery, Sports Traumatology, Arthroscopy, ISSN 0942-2056, E-ISSN 1433-7347, Vol. 18, p. 404-408Article in journal (Refereed)
    Abstract [en]

    The repair of the capsuloligamentous complex during shoulder stabilisation procedures can be followed by a persistent restricted capacity of external rotation. The prognostic importance of this loss in external rotation for patient satisfaction has not previously been evaluated. We therefore followed 68 consecutive patients operated for recurrent traumatic unidirectional anterior instability of the glenohumeral joint to assess the association between loss of external rotation and patient satisfaction. All patients underwent open Bankart repair. Two independent observers carried out a follow-up (5 years on average) after surgery. At follow-up, recurrent dislocation had developed in four of the 68 patients (6%). The median pre-operative Rowe score was 65 (range 42-87), which can be compared with 92 (range 46-100) at the follow-up. Three patients rated their outcome as poor, 13 as fair, 23 as good and 29 as excellent. There was a five-fold increased risk for a poor or fair outcome among patients with loss of external rotation in 0° of abduction (age- and gender-adjusted odds ratio [OR] 5.3; 95% confidence interval [CI] 1.3-22.0, P = 0.0007). A linear association between the degree of loss in external rotation and patient dissatisfaction was found. The risk of being dissatisfied, independent of recurrent dislocation, occasional pain, positive apprehension test, age and gender, more than doubled (OR 2.6; 95% CI 1.4-4.8, P = 0.002) for every 10° of post-operative loss of external rotation. Loss of external rotation almost explained all of the variation in patient satisfaction with a population attributable risk of 0.85 (95% CI 0.20-0.94). We conclude that open Bankart repair with a modified Rowe procedure is an excellent surgical option regarding stability, but restriction in external rotation reduces the likelihood of a satisfied patient.

  • 17.
    Sandborgh, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Dean, Elizabeth
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. University of British Columbia , Vancouver , Canada.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Norwegian Institute of Public Health , Nydalen , Oslo , Norway.
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Fritz, Johanna
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    von Heideken Wågert, Petra
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Moberg, Johan
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Overmeer, Thomas
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Örebro University, Örebro, Sweden.
    Snöljung, Åsa
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Johansson, Ann-Christin
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Integration of Behavioral Medicine Competencies into Physical Therapy Curriculum in an Exemplary Swedish Program: Rationale, Process and Ten-year ReviewIn: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040Article in journal (Refereed)
    Abstract [en]

    In 2004, Mälardalen University, Sweden, introduced a new undergraduate entry-level physiotherapy program. Program developers constructed the curriculum with behavioral medicine content that reflected the contemporary definition and values of the physiotherapy profession aligning it with current best practices, evidence, and the International Classification of Functioning, Disability, and Health (ICF). The new curriculum conceptualized movement and function as modifiable behaviors in that they reflect behavioral contingencies, perceptions, beliefs, and lifestyle factors as well as pathophysiology and environmental factors. The purpose of this article is to describe how one university accordingly structured its new curriculum and its review. We describe the rationale for the curriculum's behavioral medicinecontent and competencies, its development and implementation, challenges, long-term outcomes, and its related research enterprise. We conclude that physiotherapy practiced by our graduates augments that taught in other programs based on accreditation reviews. With their expanded practice scope, graduates are systematically practicing within the constructs of health and function conceptualized within the ICF. Our intent in sharing our experience is to exemplify one university's initiative to best prepare students with respect to maximizing physiotherapy outcomes as well as establish a dialogue regarding minimum standards of behavioral medicine competencies in physiotherapy education and practice.

  • 18.
    Sandborgh, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    von Heideken Wågert, Petra
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Snöljung, Åsa
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    IMPLEMENTATION OF BEHAVIORAL MEDICINE IN A PHYSIOTHERAPY UNDERGRADUATE CURRICULUM STUDENT EVALUATIONS2018In: International Journal of Behavioral Medicine, ISSN 1070-5503, E-ISSN 1532-7558, Vol. 25, p. S64-S65Article in journal (Other academic)
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