Teaching clinical reasoning in gerontological physiotherapy: Experiences and perceptions of clinical supervisors

ABSTRACT

Introduction

Teaching clinical reasoning to physiotherapy students is essential for preparing them to work effectively with patients.

Objective

This qualitative study aimed to explore the experiences and perceptions of clinical supervisors of teaching clinical reasoning in gerontological physiotherapy.

Methods

Australian-based clinical supervisors for student placements in gerontological physiotherapy (n = 9) participated in individual semi-structured interviews via videoconferencing. Data were analyzed using Braun and Clark’s reflexive thematic analysis.

Results

Four themes were developed from the data: 1) Preparedness for placement: students and supervisors; 2) Dynamic placement adaptations to meet individual learning needs; 3) Negotiating clinically complex and variable patient needs; and 4) Crafting learning opportunities amidst complexities. Clinical supervisors perceive that teaching clinical reasoning is influenced by student and supervisor preparedness and the complexity of gerontological practice. Supervisors engage in planning prior to placements, adapt tasks, discussions and feedback throughout the placement, and promote multi-disciplinary learning experiences to highlight person-centered and collaborative care.

Conclusion

This research enhances physiotherapy academics,’ clinical supervisors’ and students’ understanding of the factors influencing teaching clinical reasoning to students in gerontological settings. The challenges and strategies identified can improve students’ and supervisors’ preparedness for placements, assist them to negotiate complexity and create opportunities to strengthen the learning experience.

KEYWORDS:

• Qualitative
• clinical reasoning
• gerontology, physiotherapy

Introduction

In Australia and globally, there is a shift in population distribution toward older ages (Australian Institute of Health and Welfare (AIHW), 2021; United Nations Population Division, 2019). Older adults often present with disproportionately more complex healthcare needs (AIHW, 2021). Multi-morbidity and geriatric syndromes (e.g., frailty, cognitive impairment, incontinence and falls), increase in prevalence with age (AIHW, 2018). In the Australian context, older adults frequently engage with allied health services, such as physiotherapy (AIHW, 2021).

Physiotherapists require appropriate support and training to work effectively and safely in complex care settings with older adults (Wong, Odom, and Barr, 2014). Hobbs, Dean, Higgs, and Adamson (2006) found Australian entry-level physiotherapists’ knowledge of managing common conditions affecting older adults was below the expected level for graduate-level practitioners. Similarly, a 2014 report from the United States (Wong, Odom, and Barr, 2014), purports that graduating physical therapists are underprepared to deliver effective services for older adults (Wong, Odom, and Barr, 2014). These authors propose introducing specific gerontological competencies and clinical experiences to improve students’ attitudes and decision-making skills (Wong, Odom, and Barr, 2014). Multi-morbidity, atypical presentations, patient profiles and busy clinical environments present some unique considerations that potentially impact the teaching of clinical reasoning (Elvén and Dean, 2017). Teaching clinical reasoning is integral to preparing physiotherapy students to provide care and make clinical decisions when working with older adults.

Clinical reasoning may be defined as: “a process in which the therapist, interacting with the patient and others (such as family members or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgment and knowledge” (Higgs and Jones, 2008 pp 3–18). This definition was used for the purposes of our study.

Clinical reasoning is integrated within physiotherapy pre-professional curricula and is recognized as critical for effective physiotherapy practice (Christensen et al., 2017). Physiotherapy students value learning clinical reasoning during placements (Gordon and Milanese, 2015). However, physiotherapy clinicians can find it difficult to teach (Delany and Bragge, 2009). Various strategies suggested in the literature to assist clinical supervisors include “making thinking visible” (Delany and Golding, 2014) and “communicating reasoning” (Ajjawi and Higgs, 2012). Despite reported consensus and agreement among academic staff on the conceptualization and frameworks around clinical reasoning in physiotherapy (Sole, Skinner, Hale, and Golding, 2019), there is variability in teaching methods across programs and within sub-specialties (Christensen et al., 2017). This may be due to differences in contextual factors (e.g., patient presentations, busy environments) and knowledge required for clinical decision making in different settings (Sole, Skinner, Hale, and Golding, 2019; Wijbenga, TJ, and Driessen, 2019).

Many factors can influence the development of clinical reasoning for students on placements. A 2019 European study (Wijbenga, TJ, and Driessen, 2019) that investigated perspectives of physiotherapy students and clinical supervisors, highlighted the pivotal role of the supervisor in designing experiences to foster clinical reasoning (Wijbenga, TJ, and Driessen, 2019). Similarly, another study explored the views of physiotherapy students on their hospital placements and identified the critical impact of the clinical educator on guiding learning (Lewthwaite, Gray, and Skinner, 2023).

The terms clinical supervisor, clinical educator and clinical tutor have been used interchangeably within the context of physiotherapy placements in Australia (Australian Physiotherapy Council, 2017). For the purposes of the current study, the term clinical supervisor is used as the state-wide employment agreement restricts the use of the term clinical educator to senior employees only (Victorian Hospitals Industrial Association, 2021). A clinical supervisor may be defined as “a physiotherapist with the responsibility for the clinical education of physiotherapy students, as designated by the education provider or clinical facility” (Australian Physiotherapy Council, 2017).

This study aimed to explore the experiences and perceptions of clinical supervisors in gerontological physiotherapy of teaching clinical reasoning to students on placement. The specific aims were to examine their current practices, identify barriers and facilitators to teaching, and explore strategies employed to foster clinical reasoning.

Materials and methods

This qualitative, interview study was conducted from February 2021 to June 2022. Human Ethics Approval was granted by the Office of Research Ethics and Integrity at The University of Melbourne (Approval number: 2021–21222 -20,463-4).

Research paradigm

This study was underpinned by the research paradigm of interpretivism, which assumes multiple subjective meanings associated with a particular experience, constructed socially and influenced by context (Brown and Duenas, 2020). This lens acknowledges clinical supervisors’ and researchers’ portrayal and construction of experiences throughout the research process.

Setting

Entry-level physiotherapy courses in Australia provide students with experiences in a variety of settings (acute, sub-acute and community) to enable graduates to competently work with a range of health conditions across the lifespan (Australian Physiotherapy Council, 2017). Gerontological clinical placements are commonly offered within public health sub-acute inpatient services known as Geriatric Evaluation and Management (GEM) units (Health Workforce Australia, 2014), which was the setting for the current study. These GEM services offer students the experience of working with older adults receiving multidisciplinary care for complex and multiple medical conditions (Department of Health, 2022).

Participants and sample size

Participants were gerontological physiotherapy clinical supervisors currently working in Australian public sub-acute inpatient GEM settings and had at least one year of clinical supervision experience in gerontology. Clinicians outside Australia were excluded, as experiences and practices may vary considerably. The research team aimed to recruit 6–12 participants to elicit in-depth, rich, and informative data (Braun and Clarke, 2006; Varpio et al., 2017).

Recruitment

The study was advertised through professional organizations, such as the Australian Physiotherapy Association, and the networks known to the research team. Participants were purposively sampled to obtain a range of work locations and years of experience (Creswell and Poth, 2016, pp 125–129). All participants provided written informed consent. Author HS had worked with some participants in previous roles but a direct supervisory relationship did not exist at the time of the study. Where such a relationship did not exist, HS established rapport at the time of recruitment.

Data collection

Each participant completed an online survey, designed to collect demographic information, prior to undertaking the interview.

An interview guide was developed by the research team using three steps: 1) considering the main aspects of enquiry; 2) refining the questions for appropriate flow; and 3) piloting by author HS with an experienced physiotherapist prior to data collection to ensure that the interview generated data relevant to the research question (Table 1) (Bearman, 2019).

Table 1. Interview guide.

Domain	Main question	Prompts
Warm up question	Can you describe a typical clinical placement block, thinking about your interactions with the students and the type of activities that they are asked do?	What type of patients do the students see? What activities do they do? What is the student vs supervisor ratio? How much time would you spend with them? What level of supervision is provided?
Definition of clinical reasoning	Visual prompt provided for definition of clinical reasoning. (1) What do you think of this definition?	Do you think this definition represents clinical reasoning in gerontological physiotherapy practice? Would you want to modify – add or remove anything?
Experiences of teaching clinical reasoning	Visual prompt provided for key stages of the clinical reasoning cycle. (2) Can you talk me through the strategies you use to teach clinical reasoning to physiotherapy students in a gerontology setting?	Explore experiences around all stages and beliefs about the most important stage/s.
Opinions about teaching clinical reasoning	(3) What do you think is unique about teaching clinical reasoning to physiotherapy students in gerontology?
Factors influencing teaching clinical reasoning	(4) Have you experienced any barriers to teaching clinical reasoning to physiotherapy students in gerontology? Can you think of an example when teaching clinical reasoning was difficult? (5) With the example you just shared in mind, can you talk me through some of the strategies you used to teach clinical reasoning in this difficult situation? (6) Can you describe what enables you to teach clinical reasoning to physiotherapy students? Can you provide an example of when teaching reasoning worked well?	For question 5 and 6 - can you specify if these barriers related to patient, student, yourself, organization? For question 6 - what made it easy e.g., collaborative practice, patient factors, contextual factors?
Methods used to teach clinical reasoning	(7) Do you use specific models or tools for teaching clinical reasoning to students in gerontology?	For example, problem lists, WHO ICF model, etc? Any other strategies like case discussions, debriefs? How does it help you to teach clinical reasoning?
Open ended final question	(8) Do you have anything else you would like to tell me about teaching clinical reasoning to physiotherapy students in gerontology?

Abbreviations: WHO ICF, World Health Organisation International Classification of Functioning, Disability and Health.

Semi-structured interviews were conducted by author HS via online videoconferencing, with a planned duration of 30–60 minutes and audio-recorded. Author HS received additional training in qualitative research methods provided by authors CM and KB with experience in qualitative research methods, semi-structured interviews and data analysis. Individual semi-structured interviews facilitated free expression and exploration participant experiences and allowed the researcher to ask follow-up questions for clarification (Liamputtong, 2020).

The definition was displayed as a visual prompt at the start of the interviews and participants were invited for their views on this definition and its representativeness for clinical reasoning within their own contexts. Key steps of the clinical reasoning cycle were also displayed as a visual prompt for the participants to foster similar understandings of the concept and definition of terms. The steps included considering the patient situation, collecting and processing information, identifying problems and setting goals, taking action, evaluating outcomes and learning by reflection (University of Tasmania, 2009). Author HS maintained reflexive notes for each interview. The interviews were transcribed with transcription software, Otter.ai (Otter.ai, Inc, California, USA). Author HS listened to interview recordings and edited the transcripts for accuracy.

Data analysis

Transcribed interview data were analyzed using the six steps of Braun and Clark’s reflexive thematic analysis (Braun, 2012), which can be used within the interpretivist paradigm (Creswell and Poth, 2016, pp 39–41; VC and Victoria, 2012). Data analysis was completed using NVivo qualitative data analysis software (QSR International Inc, Massachusetts, USA).

Familiarization. Author HS read the transcripts to build familiarity with the data, identify key ideas and generate interview summaries for member checking. Authors KB and CM reviewed a selection of summaries to ensure key ideas and concepts were represented. The summaries were emailed to individual participants for member checking within three weeks of the interview.

Generating codes. Author HS generated codes from the transcripts, representing ideas shared by the participants. Authors KB and CM also independently coded one transcript each. After completing open coding for five interview transcripts, authors HS, KB and CM discussed and debated the scope and focus of their codes. Author HS coded the last four interviews generating additional codes which the research team again met to discuss. By this time, progressively fewer new codes were being generated within subsequent transcripts.

Constructing themes. Author HS followed an iterative process of reviewing raw data, reorganizing codes into core ideas and concepts, and combining or collapsing codes when they overlapped. Eventually, author HS generated initial themes using mind-mapping. During meetings with authors KB and CM, the breadth and depth of these initial themes were discussed and debated.

Reviewing themes. Author HS re-engaged with raw data to check that the initial themes represented the data and answered the research question. During regular meetings between authors HS, KB and CM, these initial themes were refined further.

Defining themes. Author HS developed definitions which described the core idea and meaning of each theme. Author HS also gave each theme a “working” name. The authors (HS, KB, CM and BV) reconvened to revise the theme names, descriptions, and order, so that they were clear and precise.

Producing a report. The four themes generated from the data were described as results with illustrative anonymized participant quotes. Authors HS, KB,CM and BV contributed to several revisions of the report as they sought to articulate their interpretation of the meanings generated from data.

Consolidated Criteria for Reporting Qualitative Research (COREQ) was adopted tor description of study design, ensuring reflexivity, data analysis and reporting.

(Tong, Sainsbury, and Craig, 2007)

Results

Ten gerontological physiotherapy clinical supervisors were recruited and completed the online demographic survey (Table 2). One participant withdrew from the study citing personal reasons. Interviews were conducted with the remaining nine participants.

Table 2. Demographic characteristics.

Characteristics	Number of participants
Age in years
25–29	2
30–39	6
>40	2
Gender
Male	3
Female	7
Job title
Grade 3	4
Grade 2	6
Clinical setting within public health
Sub-acute	4
Geriatric evaluation and management (GEM)	5
Other	1
Highest level of education
Bachelor’s degree	6
Graduate Certificate	1
Graduate Diploma	1
Master’s Degree	2
Training in clinical supervision
Yes	7
No	3
Experience as a physiotherapist in years
<4	2
5–9	5
10–19	2
>20	1
Experience as a gerontological physiotherapist in years
<4	7
5–9	1
10–19	2
Experience as a clinical educator in years
1–2	1
3–9	7
>10	2
Experience as a gerontological clinical educator in years
1–2	4
3–9	4
>10	1
Average number of students supervised per year
0–2	1
3–9	8
>10	1
Number of students currently supervising
0	5
1–2	4
>2	1

Reviewing the definition of clinical reasoning

Participants reported that the definition of clinical reasoning used in the current study was holistic and representative of their current physiotherapy practice and teaching context.

Consolidated Criteria for Reporting Qualitative Research (COREQ) was adopted tor description of study design, ensuring reflexivity, data analysis and reporting (Tong, Sainsbury, and Craig, 2007).

Thematic findings

Four themes were generated from the data: 1) Preparedness for placement: students and supervisors; 2) Dynamic placement adaptations to individual learning needs; 3) Negotiating clinically complex and variable patient needs; and 4) Crafting learning opportunities amidst complexities. The participants described challenges and strategies used for teaching clinical reasoning to physiotherapy students within their own contexts and acknowledged some of these have applicability beyond gerontological placements.

Preparedness for placement: students and supervisors

Student and supervisor preparedness prior to placement was reported to influence the teaching of clinical reasoning. Students’ knowledge, experiences and attitudes, supervisor training, support from the university and organizational context were perceived as important factors contributing toward readiness for placement.

Student-related factors. Clinical supervisors reported that their expectations of students’ clinical reasoning abilities “would depend on their [the students] level of experience” (P2). For example, students’ corporate knowledge, understanding of operational systems and placement expectations influenced teaching clinical reasoning.

I think that people who are familiar with the programs that exist, when they come to placement; really seem to have that clinical reasoning in terms of well, this person can potentially be discharged with community-based rehab goals, they don’t need to stay in hospital (P5).

Clinical supervisors perceived a lack of enthusiasm toward gerontological placements amongst many students and suggested that students’ preferred area of work after graduation may inform their attitude toward placement.

A lot of students come into the placement thinking “I’m just doing like a GEM [Geriatric Evaluation and Management] rotation and the attitude is not always positive.

(P2)

When you ask them [students] (what) they are going to do after physio, gerontology is not the first answer they come out with. It’s often “I want to do sports or something else,” so sometimes that level of appeal might not be quite there.

(P4)

Clinical supervisor-related factors. Gerontological physiotherapy clinical supervisors reported their own clinical and learning experiences affected their teaching. Some participants noted personal experience as an enabler to teaching clinical reasoning and “also, the way others have taught me (…) I think a lot of it is based on the way I like to learn as well” (P3).

While participants acknowledged actively seeking supervision training, they also perceived a lack of formal training specifically for teaching clinical reasoning and suggested this could be an area of focus.

We [clinical supervisors] all do it, but we never actually have any formal training in it. I have covered a few things through my own learning, (…) in terms of the university perspective, we do benchmarking sessions, but that’s more on how you mark someone rather than the best way to teach.

(P4)

Reflecting on organizational factors, supervisors identified that changes in staffing could be a barrier to teaching clinical reasoning, but clear directives from the organization regarding placement planning assisted supervisors.

Dynamic placement adaptations to individual learning needs

Once student placements commenced, clinical supervisors continued to plan and adjust the placement according to the students’ learning needs. Participants reported these adaptations were influenced by students’ abilities, patient safety, as well as supervisors’ time pressures.

Clinical supervisors valued building rapport with the students and adapted their feedback and communication styles to create a supportive learning environment. Recognizing differences in each student’s experience, supervisors emphasized the importance of personalized learning.

The other thing is to have discussions with the students about individualizing their placement experience, to see if we can get it to their learning styles while still get them to do things at an expected standard.

(P9)

Supervisors provided close supervision in the early part of the placement by completing orientation, observation sessions and demonstration of clinical and non-clinical tasks to model the expected standard. Some participants referred to using a “learning needs form” (where the student describes their preferred learning style, previous placement experiences and placement goals) at the beginning of the placement.

We [clinical supervisors] do like the learning needs form initially, at the start of the placement, having really clear expectations; and even if it’s [gerontological physiotherapy] not the desired area of choice, particularly what skills they’ll [students] still be able to take from it.

(P4)

Supervisors reported providing students with experiential learning opportunities and carefully scaffolding their learning guided by students’ abilities and patient safety. They described breaking down the clinical encounter into manageable tasks and slowly introducing new learning opportunities during the placement.

Usually with initials [first assessment], we get them [students] to do the subjective [assessment] and come back to us, we talk through a plan, and they conduct the assessment. As they go through the placement, they become more independent and start doing full assessments.

(P7)

Participants provided various examples of individually modifying the level of support and supervision for students depending on the students’ confidence and clinical reasoning abilities throughout the placement.

I often get a good judgement by the first day to see where they [the students] are at and if they are fairly confident, I give a bit of autonomy to manage their caseload; the less pro-active (the students are), the more I would hover and stand outside … to jump in and do the session.

(P3)

Managing the responsibilities of their own role and student supervision was consistently reported as a challenge, “There are always other commitments: non-clinical things, understaffing, bed pressures … ” (P2). Supervisors sought assistance from other staff to help with supervision or offload clinical duties. They also described juggling their own schedules to be more available and setting up students with self-directed learning tasks.

Negotiating clinically complex and variable patient needs

Supervisors identified several aspects of gerontological clinical placements which contributed to clinically complex patient needs and impacted on teaching clinical reasoning. Multimorbidity, atypical presentations, variability in patient presentations and emphasis on discharge planning required supervisors to facilitate processing and prioritization of clinical information to provide safe and effective therapy.

Supervisors perceived that atypical patient presentations and multimorbidity required them to educate students to consider multiple factors contributing to each clinical presentation.

They’re [students] not able to factor in what makes this person unique in their different situations with different medical, cognition and social side of things.

(P8)

Supervisors also identified variability in patient presentations within gerontological sub-acute settings as a challenge for students. They suggested students may have difficulty in placement preparation or being able to quickly change their thinking between different health conditions.

[students] might be seeing a patient with a neurological condition and the next patient has a cardio-respiratory condition and the next person is orthopedic, which then requires a lot of different knowledge, experience and ideas for how to best treat different patients.

(P9)

Conversely, several supervisors reported that the variety of patient presentations was advantageous and facilitated teaching. “There’s so many comorbidities and such a breadth of presentations, there will always be something interesting to learn” (P7). This also enabled the selection of “a little bit more typical (and) easier to teach” (P1) patient presentations. Supervisors maintained consistency in caseload to enhance learning by “just getting them (the students) to work on similar sort of patient issues” (P1). Gaps in theoretical knowledge were addressed by self-directed learning materials on unfamiliar health conditions.

Supervisors believed that the level of risk and medical instability of patients admitted to sub-acute settings could be under-estimated by students. This posed safety concerns that needed to be factored into teaching clinical reasoning.

Being an inpatient GEM [Geriatric Evaluation and Management] ward, we still do have quite a lot of high-risk patients.

(P4)

… if the student doesn’t quite understand how unwell these patients can be, they’re not going to see those early signs.

(P6)

Conducting shared sessions with students was reported as another valuable teaching opportunity, wherein the supervisors verbalized their own reasoning, monitored the student’s skills, the patient’s progress, and assisted with more physically dependent patients and challenging situations.

I will talk through the patient and do a problem list out loud (…) what are the things that could be affecting the problem and then get them [the student] to think about it in the moment.

(P7)

Teaching students to individualize physiotherapy care in terms of therapy amount and frequency, throughout the patient’s inpatient admission, was perceived to be another challenge by some supervisors.

From our clinical skills, we need to identify where they’re [the patients] going to fit in terms of how much therapy we’re going to provide them (…) even one person can have varying levels of physiotherapy on a weekly basis.

(P5)

The impact of social “complexities” and cognitive issues were reported to be a substantial consideration in gerontological physiotherapy practice. Supervisors identified that they often needed to foster clinical reasoning around discharge planning and encourage students to consider the impact of cognitive impairment. Supervisors and teaching institutions developed tutorials on discharge planning and cognitive impairment to support students’ knowledge and clinical reasoning.

We need to teach about residential care, this can lead to other complexities with regards to power of attorneys and guardianship.

(P8)

Supervisors reflected on various strategies they used to aid information processing when students were faced with multiple contributing factors to a patient’s presenting condition. Supervisors reported tailoring their questions and verbal discussions to prompt the students to consider the patient holistically, as well as providing students more structure to assist categorizing and processing information. For example, the World Health Organization International Classification of Functioning, Disability and Health (ICF) Framework (WHO) and “problem lists” were used to provide a systematic approach toward clinical reasoning.

Crafting learning opportunities amidst complexity

Clinical supervisors acknowledged that the complexity in gerontology requires them to carefully create appropriate learning opportunities. Participants described how they taught clinical reasoning through a lens of person-centered and collaborative care.

Teaching through the lens of “person-centered care.” Several participants suggested that differences in life experiences between the students and patients may influence rapport and impact the student’s ability to gather information from the patient. Supervisors reported supporting students by engaging in role playing sessions (i.e., supervisors acted as patients) to practice building rapport and considering patient perspectives. When patient participation was limited, supervisors encouraged using alternative sources to gather information, such as family members and the multi-disciplinary team to inform clinical reasoning.

Clinical supervisors also reported that several factors affected the intersection between professional judgment guided by evidence and patient preferences, for example, cognition, social support, and the home environment. Supervisors encouraged students to consider when professional judgment may take priority and how to more effectively communicate clinical reasoning to enable patients and caregivers to make informed decisions. Teaching students how to consider this intersection (i.e., between professional judgment and patient preferences) was thought to be essential for fostering person-centered care.

I definitely agree that a patient’s preferences come into play in terms of what treatment I provide, but the patient’s preferences don’t change the evidence behind the clinical reasoning as to what the best treatment is (…) Being able to clinically reason with a patient is quite a skill, in terms of explaining to them why you want to get them up and walk.

(P6)

Almost all participants highlighted that students needed support to consider the impact of a patient’s cognition when navigating the intersection between professional judgment and patient preferences. Supervisors reported developing tutorials and encouraged verbal discussions and shared sessions with other multi-disciplinary team members to extend students’ clinical reasoning around cognitive issues, particularly as this was not often considered within physiotherapy scope of practice.

Because a lot of our patients have delirium or cognitive impairment of some sort, we need to teach them [students] how to respect the patient’s rights, make a decision and balance it with their [patient’s] cognition.

(P8)

Cognition is not something that a lot of physios understand well and know to look out for. We tend to put it the box of an OT [occupational therapist], we never really learnt it at university.

(P3)

Teaching through a lens of “collaborative care.” Clinical supervisors encouraged students to work closely with multi-disciplinary team members to enhance effective practice in gerontological settings. Some physiotherapy supervisors highlighted that the team environment in GEM settings offered students avenues to refine communication and inter-personal skills, crucial for effectively engaging with older adults. Opportunities to liaise with the multi-disciplinary team also facilitated teaching clinical reasoning through improved understanding of other team members’ roles.

I personally find that the students who work with me, their clinical reasoning skills don’t improve a whole lot but their multi-disciplinary communication and actually understanding what an OT [occupational therapist] or social worker does. (…)

(P2)

At the same time, working within a trans-disciplinary model was perceived to be challenging by some clinical supervisors as it required “building inter-disciplinary skills as wells as one-on-one patient skills” (P6). Several supervisors reported encouraging students to gain the perspectives of members of the multi-disciplinary team to inform their clinical decisions. Supervisors especially encouraged shared sessions with occupational therapists to facilitate understanding of the impact of cognition on mobility and discharge planning. Such learning experiences were identified as essential to developing effective clinical reasoning in gerontology.

Discussion

This study explored the perceptions and experiences of Australian-based clinical supervisors of teaching clinical reasoning in gerontological physiotherapy. Participants acknowledged the role of student knowledge and attitudes, supervisor training and organizational directives in creating a supportive learning environment. Clinical supervisors continued to dynamically adapt the tasks, discussions, feedback, and patient caseload during the placement to scaffold support or extend clinical reasoning. Supervisors emphasized that atypical presentations and multi-morbidity added to the clinical complexity and variability in patient presentations; and discharge planning presented specific challenges to teaching clinical reasoning. Supervisors reported strategically designing learning opportunities that encouraged teamwork and communication with the multi-disciplinary team, which enabled them to teach clinical reasoning through a lens of person-centered and collaborative care.

A key finding of the current study is the influence of student and supervisor pre-placement preparation on teaching clinical reasoning. A prior qualitative review also found development of clinical reasoning among physiotherapists was affected by factors related to the learners themselves, such as their knowledge, experiences and beliefs, along with patient and contextual factors (Elvén and Dean, 2017). Physiotherapy students have reported feeling under-prepared in the areas of clinical reasoning prior to clinical placements (Thomson et al., 2014). Various pedagogical strategies have been suggested for physiotherapy curricula, including interactive and blended learning within the university setting, and clinical practice with guided thinking (Juneja and Brekke, 2015). The role of digital educational strategies, for example “massive open online courses,” have also been explored in recent reviews as alternative pedagogical approaches (Longhini, De Colle, Rossettini, and Palese, 2021; Longhini, Rossettini, and Palese, 2021). However, there is a lack of established best practice in teaching clinical reasoning in physiotherapy in placement settings and wide variability in teaching and assessment methods (Furze et al., 2022). Clinical teaching frameworks (e.g., Myers, Bilyeu, Covington, and Sharp (2022) may help to guide clinical supervisors around their role expectations and competencies. Students and supervisors may need to consider their own digital health competencies when exploring digital education strategies as adjuncts to improve their clinical reasoning (Longhini, Rossettini, and Palese, 2022; Rossettini et al., 2021). The role of the university in effectively preparing students and supervisors for clinical placements could be further explored.

Another key finding of the current study related to the dynamic adaptations made by clinical supervisors over the placement to scaffold learning for each student. A 2022 study (Clouder, Jones, Mackintosh, and Adefila, 2022) investigated the decision-making processes used by physiotherapy clinical supervisors in Australia and the United Kingdom to progress student autonomy. The researchers developed a framework for “graduated supervision” to provide a heuristic to decrease supervision as student capabilities improved and highlighted the importance of the student-supervisor relationship and early identification of students’ learning needs on students’ progression toward professional autonomy (Clouder, Jones, Mackintosh, and Adefila, 2022). Similarly, Furze et al. (2015) report the development of clinical reasoning abilities in physiotherapy students occurred over time. This aligns with the Dreyfus model of skill acquisition (Dreyfus and Dreyfus, 1980). Strategies identified in the current study reinforce the need to initially scaffold and gradually reduce supports for clinical reasoning within complex gerontological settings.

Participants in the current study found that teaching clinical reasoning through the lens of person-centered and collaborative care facilitated effective learning in the presence of clinical complexity. Ramklass, Butau, Ntinga, and Cele (2010) acknowledge that bio-psycho-social, economic and ethical considerations highlight the need for training physiotherapy students in collaborative practice to work effectively with older adults. Furthermore, a systematic review on factors influencing the development of clinical reasoning in physiotherapists concluded a learning environment offering variety and complexity in clinical encounters and avenues for multi-disciplinary practice, promoted developing clinical reasoning (Wijbenga, TJ, and Driessen, 2019). Elvén and Dean (2017) purport that clinical reasoning happened over a continuum between “therapist-centered” and “patient-centered” approaches. Similarly, Abrandt Dahlgren, Valeskog, Johansson, and Edelbring (2022) described that physiotherapy students’ understanding of clinical reasoning included a cognitive component and a relational and collaborative process between therapist and patient. The researchers suggest selecting pedagogical approaches that prioritize the relational component to enable person-centered care. While some relevant strategies were described in the current study, the methods used by clinical supervisors to progress students’ clinical reasoning patterns toward a patient-centered collaborative process need to be explored.

Clinical supervisors in the current study perceived a lack of enthusiasm among some students toward gerontological clinical placements, which may have been partly shaped by students’ life experiences. Blackwood and Sweet (2017) reported that ageism and contextual barriers in gerontological practice influence student perspectives. Contradistinctively, they also reported that most students valued interactions with older adults, which may be due to positive prior personal and professional experiences (Blackwood and Sweet, 2017). The researchers postulate that increased opportunities to work with older adults in the curriculum and clinical practice may positively affect perceptions (Blackwood and Sweet, 2017).

Limitations

This study involved gerontological physiotherapy clinical supervisors working in sub-acute public health settings within Australia. Exploring perspectives of students and perspectives of clinical supervisors from different clinical settings could provide other insights into challenges and effective strategies. Furthermore, the current study did not explore the participants’ specific training in clinical supervision and their awareness of clinical reasoning frameworks used for teaching. This may have helped to explain some of the challenges identified in teaching clinical reasoning.

Conclusion

The current study reinforces the notion that clinical reasoning is complex to teach. As student and supervisor preparation affects teaching clinical reasoning, clinical supervisors in gerontological physiotherapy engage in considerable planning prior to placements and adapt teaching strategies throughout the placement to create a safe, appropriate and individualized learning experience. Multiple strategies are used by clinical supervisors to teach clinical reasoning. These include, scaffolding support and supervision, tailoring caseload selection, conducting shared sessions to enable demonstration, discussions for planning, post-session feedback, using tools to breakdown complexity, self-directed learning, and multi-disciplinary engagement to promote person-centered and collaborative care. Further research is needed to test strategies for teaching clinical reasoning and the impact of existing frameworks for teaching clinical reasoning on preparing the physiotherapy workforce to provide effective care in complex gerontological settings.

Acknowledgments

The authorship team would like to thank the study participants for their time and insights.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.