Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study

Abstract

Background: Clinical reasoning has been proposed to be a key attribute of health professionals. We hypothesized that clinical reasoning may be one explicit way to further the understanding of each other’s roles in interprofessional learning activities, for nurse students and physiotherapy students.

Objectives: The first part of this paper was a literature review. In the second part of the paper, we described a case study with an action-based approach.

Major Findings: The literature review showed that, although sparse, clinical reasoning has been used as a conceptual framework for students learning in interprofessional activities. Through a collaboration between clinicians and university staff, we developed a structure for interprofessional student collaboration based on narratives in combination with a clinical reasoning structure as proposed by Levett-Jones, adapted to identify the different roles. The interprofessional collaboration was found crucial for development of authentic and useful narratives to work from, where both professions had important roles. The use of a reasoning framework could scaffold student discussions to learn with, from and about each other.

Conclusions: We concluded that interprofessional learning can take place in theory courses and the use of clinical reasoning as a conceptual framework may facilitate to clarify professional similarities and differences.

Keywords:

• Interprofessional learning
• Clinical reasoning

Introduction

Clinical reasoning has been proposed to be a key attribute of a health professional.¹ Among the early publications about clinical reasoning in physiotherapy, Payton studied reasoning processes among physiotherapists.² In that study he also compared the reasoning process between physiotherapists and medical doctors, indicating the relevance of understanding the reasoning processes among different health professionals. Clinical reasoning was proposed to be important in student training.²

Clinical reasoning may be explained and defined in various ways. It can be explained as being the professional thought process, also described as a decision-making process. Research has taken different paths in furthering this understanding. In medical contexts the cognitive process has been described as conscious/analytical or unconscious/non-analytical reasoning.³ Students mainly use a more analytic way of reasoning, where they seek answers from their theoretical knowledge to explain their findings. As one becomes more experienced, the process shifts to mainly relying on patterns one recognizes that will lead to a faster decision-making process, without a full analytical thought process.

Another way of describing the clinical reasoning process is to describe it as a cycle by the steps taken in a patient encounter.⁴ Starting with considering the situation, collecting cues, processing the information to identify problems etc. The steps proposed in the cycle seem to be similar in different professions, however, the underlying perspectives and questions raised may be profession specific. Within the reasoning cycle analytical and non-analytical reasoning may be used.

From an educational perspective questions that arise include how the learning activities should be designed to enhance the clinical reasoning development. There seems to be an agreement that active participation in the reasoning process is beneficial also for development of transfer of the skills to various clinical contexts.^5–7 Further, a structured approach to practice the reasoning process seems advantageous for the ability to use clinical reasoning.^8–11

Based on previous studies we hypothesized that clinical reasoning may be one explicit way to further the understanding of each other’s roles in interprofessional activities. The first part of this paper is a literature review. In the second part of the paper we describe a case study with an action-based approach. The aim was to develop a learning activity with the intention to prepare students for interprofessional work. The study was based on a socio-cognitive perspective¹² where two professions meet and build on their understanding of professional collaboration using a framework of a clinical reasoning cycle.⁴

Method literature review

The literature review was conducted with the following steps:

(1)	The research questions were defined: How has clinical reasoning been used as a conceptual framework for interprofessional learning among students? How has it been used in undergraduate clinical and theory courses?
(2)	Relevant studies were identified by a systematic search of PubMed and Scopus to identify relevant peer-reviewed English language articles published during 2012–2017. The search terms used were: ‘interprofessional’ AND ‘clinical reasoning’. The search was then repeated without time limit, but by adding ‘student’ as a search term. The search aimed to identify studies that used the concept of clinical reasoning in an interprofessional learning context. Inclusion criteria were that the study was about students learning. After removing duplicates, 31 abstracts were reviewed manually. After abstract screening 8 papers remained for full text review. The reason for exclusion were; not involving students in interprofessional activity (n = 20), book chapter (n = 1) and review papers (n = 2).
(3)	Study selection. After reviewing the full papers, five were remaining, and three did not include students in interprofessional activity. The search was then repeated in Cinahl and AMED, however, no further studies were identified.

Results

The literature review showed that, although sparse, clinical reasoning has been used as a conceptual framework for students learning in interprofessional activities. The conceptual reference used for clinical reasoning was undefined in three of the studies^13–15 and one¹⁶ referred to Levett-Jones approach and one¹⁷ to script theory. Three of the settings were simulations as a preparation for clinical encounters, while one was a student led clinic (Table 1).

Table 1 Literature review based on the research question, ‘how was clinical reasoning used in interprofessional education’?

	Students background	Learning activity setting	Clinical reasoning strategy	Assessment	Conclusion
Seif^13	PT, OT, physician assistant, medical and pharmacy students	Interprofessional student led clinic	undefined	Perception of clinical reasoning skills	Learning can be facilitated by structuring collaboration on a more micro level
Reime^16	Nursing, medical, students	Simulated clinic	Levett-Jones model	Survey and focus group interviews	Simulated settings seem to be powerful arenas for learning
Miles^14	Speech-language pathologist, dietitian students	Hospital readiness simulation workshops with written vignettes	Undefined looking for ‘aspects of clinical reasoning’	graded responses according to rubrics	Student-reported confidence, preparedness and knowledge was improved
Ward^15	Nursing, pharmacy, medicine, social work and dietetics students	Case based interactive learning activitiesStandardized patient	undefined	Assessment of clinical reasoning behavior	Students satisfaction with longitudinal collaboration
Kiesewetter^17	A theoretical proposal		Illness script and collaboration scripts

Case study

The conceptual idea of using clinical reasoning as a framework for interprofessional learning was developed and elaborated on during a collaborative iterative process between a university and hospital staff in Sweden. The aim was to investigate how clinical teamwork could be introduced and experienced during theory courses in nursing and physiotherapy. It is here described as a case study, where our process and early findings are presented.

As part of an improvement work using an action research approach we aimed to develop an interprofessional educational module promoting core competencies adaptive to clinical practice to be used in theory courses. The aim was to identify and develop structures for meaningful learning¹⁸ and inter-professional collaboration in theory courses. We wanted to explore the opportunities by developing a joint-program stand-alone module.

Setting

Our university has a three-year nursing program and a three-year physiotherapy program, both leading to a bachelor's degree and simultaneously a license as a registered nurse or registered physiotherapist.

The two education programs are offered separately, both with modern curricula based on active learning principles. The students did not know each other and were not well acquainted with each other’s curricula or profession. The teachers have a background in the profession they teach within, and these teachers rarely co-teach across the programs. For the first cycles of development, faculty developer, hospital staff and teachers from the programs worked together and students were invited to participate in development of this new model before it would be launched with all students. The developmental process and the final model are described here. While developing a new education module we wanted to improve collaboration between on-campus education and clinical health care professionals. The overarching conceptual idea was to use the present collaboration between professionals at the hospital as an authentic action that we wanted to capture and translate into learning encounters for students.

We were seeking to create collaboration to improve students’ team skills in authentic person-centered care settings. Care was taken to explore various arenas (such as virtual and physical learning spaces) and tools to facilitate learning and discussing structures that could be used to facilitate collaboration. Early in the project we met at several occasions to discuss how team work functions and were situated at the hospital setting.

Development plan for on-campus inter-professional clinical reasoning training

Our educational approach was built upon a desire to integrate theory and practice early on in the education programs, supported by a social cognitive theory approach¹² where the students are active learners, learning by interacting in a social context and taking charge of their own learning building on actions, experiences, reflections and abstraction.¹⁹ In the integration of theory and practice we strived for authenticity and clinical contact. Being teachers with previous clinical experience we wanted to collaborate with staff currently fully occupied with patient care, to capture the current clinical professional perspective. This was important for us to ensure authenticity. A challenge we wanted to approach was that students might not be exposed to how professionals are thinking and acting early in their learning. In particular, they are not exposed to how different professionals reason. These ideas were discussed in meetings and the key challenge identified was that we as professionals were not aware of our similarities or differences in thinking. This led us to further explore learning activities that in theory are proposed to facilitate clinical reasoning. The question was if we could create opportunities for professionals from both professions to describe their thinking around a particular ‘case’ and if so, if we could use the stories told to illustrate their thinking in the profession.

One approach to promote thinking and reasoning skills are the use of clinical cases. Case-based methods have previously been suggested for use, for instance in nursing education.^20,21

Case methodology builds upon an extended interpretation of a belief in situated learning. In situated learning the learning takes place in the context/situation that you later are expected to master.²² Situated learning can be described as learning in working life. Later this has been modified to also include role-play as situated learning. Case-based methods can be used as role-play and encompasses an authentic story. The use of real life situations, such as stories written based on authentic experiences, has the potential to bridge between theory and practice, and mirror the real life. Further, to promote a learning opportunity for a group the story should be perceived as being realistic, ‘messy’ and ambiguous, meaning that you cannot make decisions only by reading a book or searching the internet. The students will need to discuss and look for different perspectives and options. Another characteristic we emphasized was that the narrative should be written from the professional perspective.²³

Clinical reasoning is situated in a patient care setting and it may involve social interaction with other health professionals, patient and family members. The reasoning processes may differ depending on the profession and situation. It has been proposed that lack of insight in reasoning strategies also becomes a barrier for student learning in clinical education.³

Further, to develop skills in working with other professionals and to learn from, with and about each other, students may benefit from an environment where they feel free to investigate issues, discuss and explore without anybody being at risk of harm. For these reasons narrative stories in active learning modules triggering interaction and discussions with other students may be beneficial. In this model, the students were exposed to a written narrative, which they could elaborate on and discuss in-between themselves.

To promote discussion between students from different professions, mixed groups with nursing and physiotherapy students were part of the setup. As a final step in the learning module the students were connected online, using software for video conference and a webcam, with clinical staff (nurse/physiotherapist) available for feedback during a discussion session. This final step aimed at strengthening authenticity in the team work and care approach. It further was an opportunity to ask clinical questions on reasoning and prioritizing in relation to a narrative case scenario.

Development process

The development process was an iterative action process involving faculty members, hospital clinical staff and students.

Short stories told from the professional clinician’s perspectives were developed in a narrative manner, reflecting the thinking and acting within each profession. These activities made use of webinars, so that the involved staff would be comfortable with the software and other aspects of web-meetings before encountering the students.

We asked for stories being anonymized while related to patient encounters diagnosed with any common disease, such as arthritis, diabetes, or heart disease. To promote the clinical reasoning perspectives, the stories were written in sequences like a patient would encounter different health professionals at different times. The perspective was always the professional’s, and how they enacted the person-centered care. Guided questions to the case authors included reinforcement of principles such as ‘avoid thinking like a medical record description’ and ‘verbalize how you as a nurse would think and act’ and used standard questions such as, ‘what would you think in a situation like this?’, ‘what would you do in a situation like this?’ ‘what would you see and care about?’. We also discussed how much information should be included in a story and how much should be kept as additional information. We aimed at keeping the stories ‘messy’ and complex, yet avoiding extensive medical information. The balance between keeping stories authentic and yet anonymized required collaboration and field testing to make sure the story was narrative in a captivating way, even though the information did not reveal any particular individual patient. When reviewing the stories in the developmental process, from a faculty developer perspective, theoretical frameworks such as the clinical reasoning cycle turned out to serve as a guiding structure to ensure information could support a discussion by giving information from at least some sections of the reasoning cycle.⁴

In class the students were divided into small groups. During the first cycle we started out with within-professional groups but soon realized that this step was more of a barrier to shared understanding. In the next step the students were split into mixed professional groups. As teachers we also collaborated across the professions to facilitate the multi-professional dialog. As a mean to facilitate the student discussions we used a scaffolding structure with headings.²⁴ During piloting, the discussion headings seemed to not assist in highlighting different professional reasoning and priorities. Further it did not promote a reasoning process expanded beyond diagnosis and decision-making for initial treatment. We then elaborated on a scaffolding structure reflecting current evidence based and outcome based health care strategies, elaborated from a model of clinical reasoning as described by Levett-Jones⁴ and including aspects of the different professional priorities and reasoning. This was used as a board plan during the student discussions (Figure 1).

Figure 1 Boardplan as a structure illustrating a clinical thought process, to be used as a support for a case based discussion. Based on the model developed by Levett-Jones⁴ adapted for interprofessional discussions

The present model of discussion structure builds on theories with person-centered approach, clinical reasoning and interprofessional learning. The use of narratives and the new structured scaffolding model for discussions seemed to promote meaningful learning in relation to understanding multi-professional teamwork. In the early evaluations from a curricula perspective it was shown that the timing of the activities during a theory course worked very well. Further, the narratives and the board plan seemed to scaffold and trigger discussions when used in small groups. There was a vast amount of agreement of the value of having these discussions in a classroom to have the time to discuss and understand the different clinical reasoning perspectives.

Discussion and conclusion

The literature review showed very limited research on the use of clinical reasoning as a conceptual model for interprofessional student education. Based on findings of the value of using active participation and a transparent reasoning structure, we have shown an example of how we developed a model for student could be exposed to similarities and differences in professional reasoning as a preparation for clinical practice.

By use of inter-professional narratives it was possible to further the students’ understanding of the core competencies to discuss, contrast and calibrate their role in relation to other professional groups and the patient, throughout a clinical reasoning process. This concept has a potential of highlighting aspects that cannot be targeted otherwise. The scaffolding structure developed based on clinical reasoning in a multi professional context seemed feasible for interprofessional interaction and collaboration in theory courses and was scalable. So far, nursing and physiotherapy students have been involved. In future steps the model will be used also with other health professional students.

Clinical placements are becoming shorter, limiting the opportunity to longitudinally follow patients and experience the professionals various reasoning processes. The advantage of using narratives from professional perspective was that it gave an opportunity for students to be challenged not only to ‘meet’ a patient once but to think like a professional and adapt to the patient with changes in health and how that leads to interaction with other health professionals. During the session they got feedback from each other and saw different perspectives on how to approach a patient and what should be prioritized. Because physiotherapists and nurses often meet the same patients it was valuable to increase the knowledge about each other’s professions during education. The module developed here could be used also with other health professional students, even a full health care team. Because of the integration of online interaction and collaboration for the later steps it could be expanded with the only requirements being a computer per team, to connect between the teams and with health care staff.

As the concepts of person-centered care is strong and emerging as well as the focus on clinical reasoning, it was valuable to work jointly with faculty, clinicians and students to further the understanding on how the different concepts can be seen as a whole in a learning module. This module was tested in the beginning of the second study year, where the students did have some but limited clinical experience. The timing seemed well suited, as they were familiar with what a hospital setting may look like, but not familiar with how the professionals would reason and collaborate.

Obstacles we identified were a need to clarify for ourselves how person-centered perspective and professional perspective are mutually important and could simultaneously be approached by narratives in learning situations. The model was developed in collaboration with clinicians, where the idea emerged of the various stories and the elaborated scaffolding structure (Figure 1). The use of narratives told from a professional perspective seemed to work well in a theory course. From our piloting we found it crucial that the narratives described a story where both professions have an important role. After testing this module our impression was that learning reasoning skills can be fostered early on in education. It was important to balance development of the professional perspective while simultaneously focusing on grasping the patient perspective. A structure prompting the different decision-making processes seems valuable to learn about and from each other. It created opportunities to reflect on approaches to health seen through different health paradigms used in the educations. The approaches became visible and seemed to play a role in understanding the differences in problem identification, suggestions of intervention and goal setting. Interprofessional encounters with students and staff, were perceived as meaningful and valuable for furthering knowledge and understanding.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

Financial support was provided through the regional agreement between Skåne Regional Council and Lund University.

Notes on contributors

Christina Gummesson is an associate professor with a background in Physiotherapy. Her current research interest involves learning augmented by digital support and approaches to authenticity in learning. Currently, she is the Director at the Centre for Teaching and Learning at the Faculty of Medicine, Lund University, Sweden.

Anne Sundén is a lecturer, RPT, PhD with background in Physiotherapy. Her current research focus is patient education, enablement, exercise and outcome measures for patients with osteoarthritis and also educational development, digital support and e-learning for students at the Medical Faculty Lund University, Sweden.

Angelika Fex RNT, PhD, is a lecturer in Nursing at the Faculty of Medicine, Lund University, Sweden.

Acknowledgments

The authors wish to express their gratitude to all collaborators including the staff (mainly nurses and physiotherapists) at Hässleholm Hospital, staff and students at the Department of Health Sciences who participated at various stages in this study.