Research Report
䢇
Expert Practice in Physical Therapy
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Background and Purpose. The purpose of this qualitative study was to
identify the dimensions of clinical expertise in physical therapy practice across 4 clinical specialty areas: geriatrics, neurology, orthopedics,
and pediatrics. Subjects. Subjects were 12 peer-designated expert
physical therapists nominated by the leaders of the American Physical
Therapy Association sections for geriatrics, neurology, orthopedics,
and pediatrics. Methods. Guided by a grounded theory approach, a
multiple case study research design was used, with each of the 4
investigators studying 3 therapists working in one clinical area. Data
were obtained through nonparticipant observation, interviews, review
of documents, and analysis of structured tasks. Videotapes made
during selected therapist-patient treatment sessions were used as a
stimulus for the expert therapist interviews. Data were transcribed,
coded, and analyzed through the development of 12 case reports and
4 composite case studies, one for each specialty area. Results. A
theoretical model of expert practice in physical therapy was developed
that included 4 dimensions: (1) a dynamic, multidimensional knowledge base that is patient-centered and evolves through therapist
reflection, (2) a clinical reasoning process that is embedded in a
collaborative, problem-solving venture with the patient, (3) a central
focus on movement assessment linked to patient function, and
(4) consistent virtues seen in caring and commitment to patients.
Conclusion and Discussion. These findings build on previous research in
physical therapy on expertise. The dimensions of expert practice in
physical therapy have implications for physical therapy practice, education, and continued research. [Jensen GM, Gwyer J, Shepard KF, Hack
LM. Expert practice in physical therapy. Phys Ther. 2000;80:28 – 43.]
Gail M Jensen
Jan Gwyer
Katherine F Shepard
Laurita M Hack
28
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Key Words: Clinical competence; Decision making; Physical therapy profession, professional issues.
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I
n almost every field of human endeavor there is
interest in understanding expertise. The argument
is made that knowing more about what experts
know, how experts think, and how they perform in
practice is essential to continued development of a
profession and preparation of the next generation of
professionals.1–3 We know very little about how experts
practice in physical therapy, that is, what knowledge they
hold, how they engage in clinical reasoning and decision
making, and what beliefs and related behaviors they
exhibit during their work with patients and families.
Identifying and understanding these critical dimensions
of expertise can give us guidance for the creation of
entry-level and continuing educational programs and
clinical residency programs as well as for structuring the
clinical practice milieu to facilitate the process of expertise development.
The practice of physical therapy is becoming increasingly complex. Rapid changes in the health care system
are placing increased pressure on physical therapists for
effective and efficient management of patients amidst
high patient turnover. Patient diagnosis, prediction of
prognosis, intervention, and patient-family education
must be done quickly and accurately. The integration of
examination, evaluation, diagnosis, prognosis, and intervention are advocated as part of routine patient/client
management.4 Eddy5 asserts that medical clinical decisions about how to manage a patient/client require
synthesis of information including the disease process,
the patient, the signs and symptoms, interventions, values, and outcomes and are done with a great deal of
uncertainty.
All of this must be done (decision making) without knowing
precisely what the patient has, with uncertainty of signs and
symptoms, with imperfect knowledge of sensitivity and
specificity of tests. . .incomplete and biased information
about outcomes, and with no language for communicating
or assessing values.5(p316)
The same is true in the practice of physical therapy.
Understanding how our expert practitioners see their
role in health care, how they gather, sort, and apply
information and knowing what beliefs guide their
patient interactions will illuminate the practice of physical therapy.
GM Jensen, PT, PhD, is Associate Professor, Department of Physical Therapy, School of Pharmacy and Allied Health, and Faculty Associate, Center
for Health Policy and Ethics, Creighton University, Omaha, NE 68178 (USA) (gjensen@creighton.edu). Address all correspondence to Dr Jensen.
J Gwyer, PT, PhD, is Associate Clinical Professor, Director of Doctoral Studies, and Doctor of Physical Therapy, Duke University, Durham, NC.
KF Shepard, PT, PhD, FAPTA, is Professor and Director, Doctor of Philosophy Program in Physical Therapy, Department of Physical Therapy,
College of Allied Health Professions, Temple University, Philadelphia, Pa.
LM Hack, PT, PhD, MBA, FAPTA, is Associate Professor and Director, Department of Physical Therapy, College of Allied Health Professions,
Temple University.
Each author contributed to concept and research design; writing; data collection and analysis; project management; fund procurement; provision
of subjects, facilities and equipment, and institutional liaisons; clerical support; and consultation (including review of manuscript before
submission).
This research was funded by the Foundation for Physical Therapy.
This article was submitted February 9, 1999, and was accepted August 12, 1999.
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Jensen et al . 29
Studying Expertise
The first generation of theories of expertise emphasized
the central importance of problem-solving skills. The
expert was someone who held a set of reasoning strategies that could be used to solve problems.6,7 In medicine,
investigators studied the relationship between clinical
problem solving and physicians’ performance8,9 and
this led to an increased emphasis on assessment and
teaching of problem-solving skills.10,11 For example,
hypothetico-deductive strategies (ie, where the clinician
transforms an unstructured problem into a structured
one by generating a limited number of hypotheses and
then using them to guide further data gathering) were
advocated as a method for teaching problem solving.9,12
Subsequent studies demonstrated, however, that the use
of a formal hypothetico-deductive strategy did not distinguish successful from unsuccessful clinical problem
solving. Individuals with varying levels of expertise were
found to not differ in the strategies they used nor in
their depth of process but in their recall of meaningful,
selective knowledge.11–13
A second generation of theory on expertise then
emerged where content knowledge and its structures
were seen as essential components of the clinical reasoning process.7,12,13 Researchers argued that differences
between experts and novices lay primarily in experts’
recall of meaningful relationships and patterns, that is,
in the structure of the knowledge rather than in a
problem-solving strategy applied to the problem. In
addition, they postulated that problem-solving expertise
was case specific and highly dependent on the clinician’s
mastery of a particular content domain.
Despite 2 generations of theory development in expertise, there are still many aspects of expertise that we have
neither adequately identified nor understand. Currently,
a third generation of researchers has been studying what
experts in the health care professions actually do in
practice.13,14 Much of this research has focused on 2
broad categories of cognitive science: (1) investigation
of the process of reasoning and (2) understanding the
structure and use of knowledge in the decision-making
process. This research has traditionally been done by
contrasting performance of groups who differ in knowledge and experience (eg, physicians with students, specialists with generalists) in laboratory-based tasks that
represent practice.1,3,13
Study of Expertise in Physical Therapy
In physical therapy, there has been interest in applying
the hypothetico-deductive model to the clinical reasoning processes used by physical therapists. Payton,15
who studied the clinical reasoning process of 10 peerdesignated expert physical therapy clinicians, reported
the use of a hypothetico-deductive model similar to
30 . Jensen et al
findings in medicine. In their comparative study of 11
expert therapists and 8 nonexperts, Rivett and Higgs16
found that all therapists working in manual therapy
generated hypotheses consistent with the use of
hypothetico-deductive reasoning process. Both of these
studies focused on the clinical reasoning process, with
little emphasis on the type of knowledge used in the
reasoning process.
May and Dennis,17 in a survey study of American and
Australian physical therapists who were considered to be
expert clinicians by their peers, described the use of
different cognitive processing styles for different clinical
problems. Expert therapists in the orthopedic area
reported more frequent use of an information processing style, where judgment is suspended until all data are
gathered and then a systematic approach is applied. This
group’s cognitive processing style was in contrast to that
of therapists working in the neurological area, who
reported more frequent use of a perceptive or intuitive
data-gathering style, that is, seeking and responding to
cues and patterns as they gather the data. These selfreport data from therapists provide evidence that cognitive processing styles may vary across clinical specialty
areas; yet, whether this difference in cognitive processing styles actually occurs in clinical practice remains
unknown.
A recent qualitative study of clinical decision-making
processes of experienced and inexperienced pediatric
physical therapists by Embrey et al18 focused on clinical
reasoning and domain-specific knowledge in pediatrics.
They described similarities and differences between
experienced and inexperienced clinicians on 4 characteristics of clinical decision making: (1) movement
scripts (movement patterns common to children with
diplegic cerebral palsy) as part of the knowledge structure, (2) rapidly occurring procedural changes within
the decision-making process, (3) the importance of
psychosocial sensitivity for positive interaction, and
(4) the necessity of self-monitoring through selfassessment. The findings of psychosocial sensitivity and
self-monitoring are consistent with previous work done
on features of expert practice in physical therapy.19,20
Embrey and colleagues proposed that movement scripts
may be part of the knowledge structure used in clinical
decision making. This study provides additional insight
into clinical decision making in one specialty area. The
data, however, were obtained by a retrospective thinkaloud procedure, removed from the clinical decision
making that occurs during practice.
In physical therapy, the question of knowledge used in
clinical practice continues to be examined.21,22 Higgs
and Titchen21 described 3 types of knowledge: propositional (derived from research), professional or craft
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(derived from practice), and personal (derived from
self). The authors suggested that a deeper understanding of the nature of knowledge underlying clinical
practice is needed.
Studying Expertise in Practice Settings
Researchers studying expertise in other health care
professions, including nursing,2 medicine,13 and occupational therapy,23 have argued that research must also be
done in the actual practice setting, the clinic, using
qualitative research methods. This emphasis on understanding everyday practice is consistent with the argument that a professional’s skillful action is adapted to the
context of practice and that learning from one’s practice
is a legitimate source of knowledge.2,21,23,24
Grounded Theory Approach to Studying
Expertise in Physical Therapy Practice
Chenitz and Swanson described grounded theory as a
“highly systematic research approach for the collection
and analysis of qualitative data for the purpose of
generating explanatory theory that furthers the understanding of social and psychological phenomenon.”25(p3)
Grounded theory has its roots in the symbolic interaction traditions of sociology and social psychology.26 This
perspective is similar to other naturalistic traditions
where the researcher seeks to understand human behavior within a natural context and from the participant’s
viewpoint. If a researcher is looking at a phenomenon
that is a process or experience over time, Morse27
suggested that the research strategy of choice should be
grounded theory. In grounded theory, the researcher
does not begin by speculating about the theory but
rather proceeds primarily through an inductive process
to study the human experience and, from that, extrapolates theory.
Using the grounded theory approach, we have gathered
data, made theoretical interpretations, and then
returned to the field to collect more data to reaffirm our
interpretations and probe new areas suggested by the
data analysis.28 Along the way, we have read whatever we
could find related to expertise to assist us both in
understanding our work and in placing this work into
the larger context of understanding how health care
professionals gain and use expertise.1,2,14,23,29 The purpose of this study was to identify the core dimensions of
clinical expertise in physical therapy practice across 4
clinical specialty areas: geriatrics, neurology, orthopedics, and pediatrics.
Method
Sample
The subjects for the study were 12 physical therapy
clinicians who were identified by their peers as experts,
Physical Therapy . Volume 80 . Number 1 . January 2000
3 each who specialized in the practice areas of geriatrics,
neurology, orthopedics, and pediatrics. A nomination
and selection process was used to identify these expert
practitioners. Officers of the American Physical Therapy
Association’s (APTA) sections for pediatrics, geriatrics,
and neurology were solicited for nominations of expert
practitioners, and a list was generated for each specialty
area except orthopedics. A recent Delphi survey of
leaders of the Orthopaedic Section and the manual
therapy community was used to generate the list of
experts in orthopedics. Subject selection criteria developed in previous work on expertise11,19,20 were used to
identify potential experts. These criteria were: having 7
or more years of clinical practice, being involved in
direct patient care at least 50% of the time, having
completed formal or informal advanced work in the
specialty area, and being someone to whom the nominator would refer a patient with complications or a
family member for care. The focus of this study was on
describing the dimensions of expert practice; therefore,
there was no attempt to determine whether these
experts achieved better outcomes with their patients or
were able to manage patients more expeditiously. Final
selection of experts was done by selecting those nominees who received the most nominations based on the
criteria and who were geographically located in a region
close to the investigator. Each investigator obtained
institutional review board approval within her academic
institution as well as within hospital settings where some
of the expert clinicians worked. All expert clinicians and
patients who were observed as part of the study signed
consent forms.
Research Design
The basic research design for this study was a multiple
case study design using a within- and cross-case analysis.30 We began the study by having each investigator
collect data on one expert therapist and by writing up
these data as a single case report. Each case report
contained 6 components: (1) personal background of
the expert and summary of professional development,
(2) identification of the types of knowledge used in
practice and sources of knowledge, (3) description of
the clinical reasoning processes, (4) description of the
expert’s philosophy of practice, (5) description of the
expert’s disposition, personal values, and beliefs, and
(6) identification of physical therapy skills. As we continued to gather data on other experts and write case
reports (each investigator gathered all the data in one
specialty area), we began to look for similarities and
differences across the case reports of the 3 therapists in
each clinical area. Then, for each of the clinical areas, we
wrote a composite case study that represented a composite description of expert practice in that clinical area. A
final component of the multiple case study design was to
develop a model (grounded theory) based on similari-
Jensen et al . 31
was the use of clinical exemplars. Participants were asked to provide examples (exemplars) of critical events in
their professional development.33
Figure 1.
Multiple case study design.
ties across all 12 case reports (Fig. 1). The mechanism
for identification, conceptualization, and elaboration of
the cases to a larger conceptual framework was a series of
researcher and consultant meetings after each round of
data collection.30,31
Data Collection Methods
The 4 investigators in this study had extensive experience in fieldwork methods and an 8-year history of
training and collaboration as a team studying the nature
of expertise in physical therapy.19,20 We have used successive data sets from a series of studies to reaffirm and
revise an evolving conceptual framework that focuses on
the clinical performance behaviors of peer-designated
expert clinicians.19,20,28 In this study, each investigator
followed a similar time and format schedule for data
collection.
Qualitative data collection methods included interviews
with peer-designated expert clinicians, on-site nonparticipant observations, videotaping patient treatment sessions, and review of documents (eg, published papers,
teaching materials, patient records). Data were collected
until saturation occurred, that is, until no new information was retrieved from the data collection. Within the
interview sessions, structured tasks were used to aid the
clinicians’ recall of important events in their professional growth and development. One structured task was
the use of a résumé sort. Participants were asked to “sort
the items on their professional résumé into groups that
reflected the relative degree of importance of each item
to one’s professional growth.”32 Another structured task
32 . Jensen et al
A video recording was used of the initial patient evaluation, at least one
treatment session, and the last patient
visit during a single episode of care for
at least 3 patients treated by each clinician. We defined an episode of care as all
physical therapy visits provided for one
patient during a “single episode” or up
to 3 months of care for patients with
chronic impairments. These videotapes
were then replayed for the therapist
and used as the basis for debriefing
interviews focused on the knowledge
and clinical reasoning process the therapist was using during the treatment
sessions. We generated an interview
guide that each of us followed in conducting our debriefing interviews with
the therapists (Tab. 1). In choosing to
study an episode of care with various patients, we hoped
to collect data that could capture the way in which
therapists routinely think about and engage in patient
management.
Data Reduction and Analysis
The data reduction and analysis process was organized
around 4 major cognitive processes that Morse34 identified as inherent in the qualitative data analysis: comprehending, synthesizing, theorizing, and recontextualizing. The steps of this process and specific tasks are
delineated in Figure 2. In the initial phase of the data
analysis (comprehending), each researcher transcribed
and coded all interview, document, and observational
data collected on the first therapist case.31 Initial coding
was done using the broad categories identified in an
earlier conceptual framework.20 The research team then
compared and discussed the coded data and developed
revised categories that more precisely identified the data
content. In qualitative research, this is the process of
moving from open coding to axial coding.35,36 Strauss
and Corbin35 described open coding as the initial coding
of the data set. Axial coding puts data together in new
ways “by making connections between a category and
subcategories.”35(p97) The new categories and subcategories developed during our discussion formed the revised
coding scheme that was used in the subsequent rounds
of data collection (Tab. 2).
The second stage of data reduction (synthesizing) was
the writing of case reports for each of the 12 peerdesignated expert therapists. Each researcher used a
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Table 1.
Interview Guide for Videotape Playback of Episode of Care
Sample questions asked as expert clinician and researcher are viewing videotape:
1. Tell me what you were thinking about as you completed your evaluation of the patient? What is your diagnosis? What evidence did you
use? How do you know what information to focus on? Where did you learn that? Where will you go next?
2. Tell me what is going on with this patient. What is your prognosis? How did you reach that conclusion? What evidence did you use?
How did you know to use that evidence and where did you learn that?
3. Tell me about your most difficult problem with this patient. How did you identify the problem? What evidence did you use? What was
your strategy for solving the problem? How did you learn to do this?
4. Tell me how you go about making clinical decisions with this patient? What is your approach? Describe an example as we go through
the videotape. Is this process of making a decision different for you now compared with when you were a novice clinician? What are the
differences?
5. What do you think your best patient care skills are? What knowledge do you draw on as you execute these skills? (Look at videotape for
specific examples.)
6. How do you know you have been effective in your evaluation and treatment of this patient?
7. What would you tell a student about how to go about decision making in this patient care environment? Would what you tell a student
differ from what you actually do? How would it be different and why?
common case report outline that followed the coding
scheme categories. Using a common structure for the
case reports facilitated the data reduction process and
allowed us to look across individual case reports in a
comprehensive fashion.31 A copy of the case report was
sent to each peer-designated expert for review and
verification (member check). Any comments received
were integrated into a revised case report.
During the third phase (theorizing), we met as a
research team with each investigator contributing a
preliminary analysis and a set of working assertions
across her 3 cases. All case reports were read by all of the
researchers and reanalyzed by additional comparison
and interpretation across cases. Conflicting interpretations of the cases were discussed, and consensus was
reached when case data from most of the cases were
found. This analytic strategy is called “pattern matching
and explanation building.”30
An additional component of our data analysis and theory
development at this stage was the use of 3 expert,
non–physical therapist consultants who were university
professors and well published in the areas of decision
making, medical expertise, and qualitative research.
After we identified their expertise from published
research, we contacted them, and they agreed to provide
consultation to our study. These experts met with us at
the beginning of the project and after data collection on
2 therapists. They also reviewed and commented on our
case reports. Their role was to provide us with an
external perspective in building the theoretical formulations from the data and to afford us an external peer
review for our case construction and interpretations.37,38
These consultants were extremely valuable in identifying
our blind spots, challenging our assumptions, and moving our work to a higher conceptual level.
The fourth and final stage of data reduction (recontextualizing) was the construction of 4 composite cases,
Physical Therapy . Volume 80 . Number 1 . January 2000
each based on the 3 specialty area case reports. A
cross-case analysis of the composite cases was done to
develop a grounded theory that describes the core
dimension of expert practice across these cases.36
Standards of verification. Although experimental and
quasi-experimental research refers to reliability and
validity, naturalistic research, which relies on qualitative
data, refers to the dependability (similar to reliability),
credibility (similar to internal validity) and transferability (similar to external validity) of the data.37 The
verification process used in this study included the
following methods to ensure dependability and credibility of the data30,31,37–39:
1. Prolonged engagement and persistent observation in
the field.
2. Triangulation of the data through the use of multiple
data sources, multiple methods, and multiple investigators. For example, if multiple expert clinicians tell
multiple investigators in interviews how important
teaching is to their work, if teaching patients and
families is observed in nearly every patient encounter,
and if the videotaped data reviewed by others clearly
portrays teaching, then the data are “triangulated,”
and we can conclude with reasonable assurance that
the centrality of teaching to the practice of these
expert clinicians is both credible and dependable.
3. Member checks. Each of the case reports was
returned to the expert clinician to review and make
changes relative to accurate portrayal of both content
and meaning.
4. Peer review or debriefing at each stage of the case
construction. By reviewing each other’s data and
assertions and by having our consultants review and
comment on the data, our theory development blind
spots and biases were brought to light and
challenged.
Jensen et al . 33
Results
Clinician Profiles
A professional profile was compiled on
each of the 12 clinicians (Tab. 3).
These clinicians had practiced in a
diverse array of clinical settings, with
their clinical experience ranging from
10 to 31 years of practice. All of the
clinicians had acquired specialty education through a combination of shortand long-term continuing education
courses (eg, clinical residency programs of 3 months’ duration or longer). All of the clinicians were actively
involved in teaching in a variety of
settings, and 11 clinicians were active
members of APTA.
Conception of Physical Therapy
How do the peer-designated experts
view being a physical therapist? The
Figure 2.
theoretical model in Figure 3 repreCognitive processes involved in qualitative data analysis. Adapted from Morse.34
sents 4 major dimensions of expert
practice in physical therapy that were
identified as a result of our data analy5. Negative case analysis. By looking for data that did
sis: knowledge, clinical reasoning, movement, and virnot fit the direction of the ongoing analysis, each
tues. At the center of this expert practice model is the
analysis was challenged. The results, therefore, reflect
therapist’s conception of practice that emerges from the
the preponderance of data rather than isolated
4 dimensions. This conception of practice represents the
instances.
expert therapist’s vision of what it means to practice
physical therapy. This conception includes the thera6. Rich, thick description. Much of the data is presented as
pist’s beliefs about the role of physical therapy in health
direct quotations, which are considered low-inference
care and how she or he works with patients and families.
data. That is, no inferences are made without supporting data taken directly from the respondents. PresentaThe expert therapists in this study shared a relatively
common understanding of their role as physical theration of thick data allows the reader to determine the
credibility of the researchers’ interpretations.
pists, regardless of clinical specialty area. Practice begins
and ends with patients. This understanding translated
Theoretical Model of Expert Practice
into listening intently to patients’ stories, understanding
Evidence drawn from the 4 composite case studies was
the context of the patients’ lives in designing and
implementing treatment programs, and collaborating
used to illustrate the 4 dimensions of expert practice.
with and teaching patients and families about regaining
These data were originally drawn from hundreds of
function and enhancing their quality of life. In addition,
pages of transcripts, observational data, interpretive
these therapists did not judge difficult patients or label
memorandums, and videotaped recordings. Because of
them as a “noncompliant or malingering,” but instead
manuscript page limitation, examples of representative
assumed responsibility for trying to solve what they
data are included in this article. Because interview
called “complex clinical cases.” Discussion of these 4
quotes are the most concise form of data, we have
chosen them to provide illustrative data. The reader
dimensions of expert practice illustrates how this conshould be aware that although single quotes are used,
ception of physical therapy is constructed.
the data have been well triangulated to maximize credibility and dependability. Readers interested in reading
Multidimensional Knowledge Base
the composite cases that present the in-depth findings
This group of peer-designated experts had a deep underfrom each of the specialty areas as well as expanded
standing of their clinical specialty knowledge that was
interpretation of the data are referred to the book
multidimensional and centered on the patient.
Expertise in Physical Therapy Practice.40
Although professional education was an initial source of
34 . Jensen et al
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knowledge and the beginning point for
practice, it was not enough; they were
highly motivated to continue learning.
The first year out of school, I immediately felt like I had to go back to the
things I learned in physical therapy
school and refile everything, because
everything I learned was from one perspective and I needed to immediately
pull it out by diagnosis. . . .I realized
when I did that what I had for any given
diagnosis was incomplete. . . , so I went
to the library and started looking up
spina bifida or any diagnosis and just
pouring through the articles. This was a
completely different type of learning,
and I just loved it. (Pediatric Clinician
[PC])
I was at this clinic doing what I had
learned in school and from a long-term
course, and what I would find is that
patients I would treat and could not help
would go to see another practitioner.
Then, in 2 or 3 months, I would see
them and they would say they saw this
practitioner and were helped in 1 or 2
visits. I said to myself, “I have to find out
what that person is doing.” (Orthopedic
Clinician [OC])
Table 2.
Revised Coding Scheme
Concept
Definition
Background information
Personal and professional background and
experience
Conception of physical therapy
How therapists think and talk about their work;
values and beliefs that underlie their actions,
their views about health and illness; how one
actually conducts practice
Clinical practice and reasoning
Evidence of decision making; kinds of thinking
and reasoning; philosophical school of
thought; evidence of reflection
Knowledge domains
Content
Knowledge specific to specialty or physical
therapy
Patients
Knowledge of human behavior; insights into
patients
Teaching
Knowledge of teaching patients
Knowledge of self
Knowledge of own self; confidence; growth as
person and professional
Knowledge of context
Knowledge of the larger picture; role of work,
environment; health care system
Sources of knowledge
Mentors
Professional education
Patients
Colleagues
Self-education
Reading
Physical therapy skills
Clinical mentors were another source
of knowledge and were instrumental in
facilitating the learning process of
these expert clinicians. They admired
these mentors for their skills and ability to help patients,
particularly the difficult or tough cases. Usually, it was
not just one mentor, but a series of mentors who were
present at different points in their career. These mentors stimulated their thinking and helped them understand and sort out complex cases.
This person was a powerful role model for me. She was
thinking in ways that other people weren’t. She was very
criticized for her research, but definitely a hard thinker.
(Neurologic Clinician [NC])
I basically worked 7 days a week. . . .You were asked to take
it all in and synthesize the information with a live patient.
You were forced to make decisions, and you made a lot of
mistakes, but you learned. I think the clinical mentorship is
what helped me learn light-years faster. (OC)
One of the most important sources of their knowledge
was their patients. Listening to patients was an essential
evaluative skill. Our videotapes of experts practicing
demonstrated consistent active listening skills: keeping
eye contact; sitting at the same level as the patient;
Physical Therapy . Volume 80 . Number 1 . January 2000
Evidence of use of manual skills; technology;
equipment; use of touch
maintaining an intense, focused interaction with
patients; and building their questions on the patient’s
responses. A central focus of the patient interview for the
experts was to have the patient tell his or her story rather
than having the therapists initiate a series of questions to
which the patient must respond. Experts confirmed this
in their interviews.
You get a lot of good information. . . .You just let your
patients talk and give it to you as they want it to come out.
(OC)
One thing that I think I’ve really improved on with practice
. . .and because of specific course work I’ve had with specific
people is shutting up and listening. . . , and I’ve gotten
much more information from listening than I ever did from
structuring my questions. . . .It really isn’t a problem getting
the parents to tell you about the child. It’s mostly just giving
them the permission to tell you. . .and acknowledging,
honoring what they are saying. (PC)
Their use of knowledge goes beyond the patient’s movement problem or mechanism of injury to understanding
the patient, their support system, and activities at work
Jensen et al . 35
Table 3.
Professional Profile of Peer-Designated Expert Therapists (n⫽12)
Clinician and
Years of Clinical Educationa
Specialty Area Experience
(Degrees) Practice Settingsb
Advanced Specialty
Educationc
Teaching
Experienced
Professional
Involvemente
Orthopedic
clinician 1
31
BS
MS
Acute care
Rehabilitation
HMO
PP (owner and
corporate)
CE
LTC
CE
Clinical faculty
(LTC)
APTA
IFOMT
Orthopedic
clinician 2
19
BS
MS
Acute care
HMO
PP (owner)
CE
LTC
CE
Clinical faculty
(LTC)
APTA
IFOMT
Orthopedic
clinician 3
31
BS
Acute care
Rehabilitation
PP (owner)
HMO
Military
CE
LTC
CE
Clinical faculty
(LTC)
Academic
APTA
IFOMT
Pediatric
clinician 1
15
BS
MS
Pediatric clinic/school
Acute care
CE
NDT
CE
APTA
Clinical instructor NDTA
(CI)
Academic
Pediatric
clinician 2
30
BS
MS
PhD
Rehabilitation
Acute care
UAPP
PP (owner)
CE
PNF
CE
CI
Academic
APTA
Pediatric
clinician 3
24
BS
MS
PhD
Adult (long-term care)
Acute care
UAPP
Consultant (state board
of education)
CE
NDT
CE
CI
Academic
APTA
NDTA
Geriatric
clinician 1
23
BS
MS
MPA
Acute care
Rehabilitation
Home care
Nursing home
Military
GCS
NCS
CE
CI
CE
APTA
Geriatric
clinician 2
25
BS
Certificate
Outpatient practice
Home care
Nursing home
Military
CE
CI
CE
APTA
Geriatric
clinician 3
36
BS
Acute care
Nursing home
Geriatric center
CE
CI
CE
None
Neurologic
clinician 1
10
BS
MS
Rehabilitation
Outpatient practice
Home care
CE
NCS (pending)
CI
CE
Academic
APTA
Neurologic
clinician 2
15
BS
MS
Research laboratory
Rehabilitation
Acute care
NCS
CE
Academic
CE
APTA
Neurologic
clinician 3
13
BS
Certificate
MS
Rehabilitation
NDT
CE
NCS
CI
CE
Academic
APTA
a
BS⫽Bachelor of Science, MS⫽Master of Science, PhD⫽Doctor of Philosophy candidate, Certificate⫽certificate in physical therapy, MPA⫽Master of Public
Administration.
b
HMO⫽health maintenance organization, PP⫽private practice, UAPP⫽university affiliated pediatric program.
c
CE⫽continuing education, LTC⫽long-term course, NDT⫽certified in neurodevelopmental treatment, GCS⫽geriatric certified specialist, NCS⫽neurology
certified specialist, PNF⫽certified in proprioceptive neuromuscular facilitation.
d
CE⫽continuing education, LTC⫽teaching in long-term course, CI⫽teaching in clinical education, Academic⫽teaching in academic classroom.
e
APTA⫽American Physical Therapy Association, IFOMT⫽International Federation of Manipulative Therapists, NDTA⫽Neurodevelopment Teachers Association.
36 . Jensen et al
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and home. Knowledge embraced by experts in pediatrics, neurology, and geriatrics included normal and
abnormal physical, psychological, and social development as well as psychomotor status.
Today, I was doing a consultation with a much richer
background of knowledge, not just about child development, but about family issues, about adulthood interactions,
about early intervention policy at the national level. . .a
general theoretical base about seeing the child as an
integrated whole. (PC)
Premorbidly, this patient (with a severe cerebrovascular
accident) sounded like a real card. He is in his 80s, but he
went dancing probably 3 or 4 nights a week. . . .So premorbidly he was very active. (NC)
Often people come [to a physical therapist] after they’ve
had injuries, and they’re fearful, depressed, thinking “This
is the end for me.” And I say, “Wait a second, you’ve got this
life expectancy ahead of you. How are you going to live? Are
you going to succumb to this injury, or are you going to try
to rehabilitate to the highest potential?” (Geriatric Clinician
[GC])
For peer-designated experts in orthopedics, although
there was acknowledgment of understanding relevant
social and psychological factors, the specific focus was on
the movement problem and teaching patients to manage
this problem.
We look at the problem and ask what is it that is keeping this
patient from moving? Is it physical? Is it psychological? Is it
emotional? Sometimes it is emotional, and by that I mean
they have a belief system that if they move they will get
worse. . . .What they are here for is to understand their
problem and become their own therapist. The patient must
be involved in his or her own therapy and must understand
what I am doing and become part of what I am doing. (OC)
Peer-designated expert clinicians were much more
focused on the knowledge they had gained learning
from patients in their practice than on knowledge
gained from traditional academic content areas such as
anatomy, biomechanics, or pathology. They had compiled both breadth and depth of clinical knowledge that
had evolved through their own thinking about practice
(reflective process).24 Interpretation of a patient’s signs
and symptoms, management of a patient through consultation with other professionals, and analysis of what
worked and what did not work have significant meaning
for these experts.
[This expert spoke of grappling with understanding all of
the body’s systems because the patient should be viewed as
a whole person.] I try to see the musculoskeletal folks
having some neurological organization to that musculoskeletal performance or that biomechanical performance. . . .I
don’t think the neurological system and musculoskeletal
Physical Therapy . Volume 80 . Number 1 . January 2000
Figure 3.
Core dimensions of expert practice in physical therapy.
system are separable. . . .To learn something, you’ve got to
start to categorize or discriminate, but understand the
whole patient. (GC)
I feel sometimes I form opinions pretty quickly about
certain patterns. I get an intuitive feeling about problems
after I have observed patients for awhile. . .people’s (clinical) problems and how well they will typically do and what
to expect. (NC)
When I hear information that conflicts with what I feel I’ve
known to be true when I actually have watched a child, then
I do question it. I want to explore it further before I just take
information from someone else if it really conflicts with
what I’ve experienced in the clinic. (PC)
I constantly try to make sense to see how certain clinical
pictures behave. If you go in and listen to the patients, they
will tell you. (OC)
Thus, these peer-designated experts continually expand
their knowledge base by thinking critically about their
practice. Patients are a powerful, central, valued source
of clinical knowledge.
Clinical Reasoning: Contextual Collaboration
Collaboration between therapist and patient was central
to the clinical reasoning process. The patient as a valued
and trusted source of knowledge was a critical focus in
the assessment process. Therapists focused on the
patient first as a person. For example, what valued
activities or goals did the patient have, and how did
movement problems interfere with those activities? What
kind of support did the patient have at home and work?
Patient or family data were selectively gathered and
specific to the case.
Jensen et al . 37
You have to learn what the patient wants within the first 5
minutes because then you can focus your patient and say, “If
we can change this and this, we might be able to get you
back to horseback riding.” What are your hobbies? Are you
doing them now? Can you work? What do you expect from
me? What do you do? These are the kinds of questions to
help you focus on what is meaningful to the patient. (OC)
I think about making the task challenging to patients but at
the same time enabling them to carry out the activity. I am
always thinking about the long-term goal and working in
that direction, trying to stimulate context, the environment
as much as possible even if I am in the clinic. (NC)
For these peer-designated expert clinicians, the medical
diagnosis was a supplemental, additional piece of data,
but not as central as what was happening with the patient
functionally.
The diagnosis [medical] itself is not as important as functionally what am I seeing that is happening. I like to know
the diagnosis, especially when it comes to fractures and
other conditions. . . ,but what is the reason their mobility is
jeopardized? Is it a little bit of arthritis? Is it a little bit of
neurological problems? Is it a little bit of stenosis? (GC)
Once the problem(s) are identified and the context
understood, the therapist engages both in collaborative
problem solving with the patient and family and in
educating them about movement and function as the
intervention proceeds.
I feel I spend the majority of time explaining to people what
the problem is and then teaching them the ideas behind the
therapy and then getting them to help me design their
exercise program. They do all the work. When they come
back, I check their progress. The more I explain to them the
idea behind the intervention, the more they buy into it.
(NC)
A parent knows a child better than anybody who sees a child
once or twice a week. And I really have to respect their
instinctive ways of interacting with their kids. (PC)
The therapist is accountable to the patient for the success of
the program. It must make sense to the patient, or the
therapist should answer questions until it does make sense.
The success of the treatment depends upon the effectiveness of the patient’s role as patient/therapist. Patients must
be in a position of control in the treatment process and
must be willing to make changes in both behavior and
lifestyle that are often necessary to achieve maximum
recovery. (OC)
As a physical therapist, you teach, and knowing how to teach
is so important and enables you to be more successful. . . .If
the patient does not understand what is happening to
himself or herself, then the patient cannot make the
necessary changes in behavior nor can the patient fully
comply with the therapist’s activities. (GC)
38 . Jensen et al
In their clinical reasoning process, these therapists were
not afraid to be innovative and then evaluate and learn
from their ongoing reflective process. They were challenged by their patients and welcomed the opportunity
to learn from their patients.
You learn to teach yourself. You need to ask questions, to
think about what you are doing. I can see 2 people with a
vestibular injury, and all their test results look the same.
And these 2 people are completely different in terms of how
they’re doing with treatment. Why is that? How can I
explain that? Trying to figure it out helps you to begin to
identify the problem, and that makes for good scientific
inquiry. (NC)
Movement: A Central Focus and Skill
Movement was a central focus for all of the therapists
studied. In the data gathering process, the therapist’s
hands-on skills and assessment of movement was done
through palpation and touch.
I have a tremendous memory for how the child feels in my
hands, and I often don’t see these kids for 6 months. I make
notes after an examination. I’m glad to have my notes, but
I trust my memory. (PC)
I try to use touch a lot. It’s one of the first things that
attracted me to physical therapy as opposed to medical
school. And that is how we get to know our patients. We
handle our patients. (GC)
I have to feel what the patient is doing. Somebody will say,
“Well, what do you think is wrong?” or “What can I do to
make his gait better?” and I say, “Well, I don’t know, let me
feel.” And then I can say, “There’s not enough weight shift.
You need to facilitate this aspect of the movement and so
on.” (NC)
In pediatrics, play was used to evoke movement for
evaluation and treatment. The experts provided an
explanation for the importance of play that was more
encompassing than fun and movement.
See, now he’s starting to play with me, he is starting to play
with my face. He wants me to puff air into my cheeks, and
you know that silly game kids do. See, I feel that level of trust
is just worth a million dollars. And now we are getting all the
physical stuff we need. (PC)
Function was considered the reason for the focus on
movement. Returning the patient to a prior level of
function or designing exercises that fit with the patient’s
work or home environment or avocational activities was
a continual focus.
[From video observation] You see here I am allowing the
patient to move the way she wants to move. [Patient is going
down stairs by leaning forward using both handrails and
descending step over step.] I have had patients who have
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never gone up their stairs step over step with alternating
legs, so I’m not going to teach them something new. (NC)
[From video observation] Our goal here is to get you back
to golf. [Therapist demonstrates the exercise to the
patient.] Now let’s try that again. You are not strong enough
yet to go low. (OC)
Use of equipment, either in the clinic setting or for
home programs, was very limited. Patients were treated
with the therapists’ hands and instructed in exercise
programs that were usually few in number, simple, and
specific to functional movement.
I look at the patient as being a mystery. I love to get a new
patient because it is a new problem to solve. It is exciting,
and if it wasn’t, I wouldn’t be practicing today. (OC)
I don’t think I’ve ever reached a point where I was what
you’d call burned out. (GC)
I get nourishment from my teaching and my writing and my
research. . . .It helps my thinking with my patients. (GC)
The only part I can’t tolerate is feeling that I’m not doing a
good job for the patients. That’s the part I can’t tolerate.
(NC)
Home exercise programs often used readily available
items in the home environment and were often a vehicle
of collaborative problem solving for the patient and
therapist.
Consistent with their interactions with patients was the
experts’ ability to communicate a sense of commitment
and caring about the patient. These therapists saw
patient advocacy as a vital professional role, as demonstrated by the amount of time they spent working to get
what was best for the patient through telephone conversations with case managers, writing additional letters or
documentation, or serving the local and professional
community in policy areas.
I am of the belief that the majority of people will not do a
lot of exercises. Part of the (physical therapy) diagnosis is
done with exercise. Exercise helps me decide what is wrong
with the patient. When I am not really clear, I give them one
thing to do at home, and then I will get more information.
I tell them they learn and I will learn from this exercise.
(OC)
I expect patients to be better within a certain this period
of time, and if it doesn’t happen, they call me. This call
method has evolved over time and gives the patient a
process for thinking about where I can assist. Otherwise, I
am doing nothing more than a person who hands out a
sheet of paper and says go home and do your exercises.
(OC)
Beyond demonstrating, guiding, and facilitating functional movement in patients, all of the therapists used
their hands to communicate with patients (eg, for reassurance, facilitating safety, and comfort and praising).
Touch was often accompanied by congruent verbal
responses.
I have spoken with the MD at the rehab center who is
following the patient and told her about the discharge from
home care and my anticipation that she would be followed
by outpatient therapy. The MD said she would write the
prescription. Then I made a follow-up call to the secretary.
The patient did not have the prescription yet from the MD.
So a week and one half later, I made another contact with
the physician, and she wrote it then while I was with her.
Then I checked with the secretary, and she still didn’t have
the prescription. Now, I am going to have to call the MD
again. (NC)
Well, I was cursing my physical therapist when she was
making me pick up things off the floor. But then I dropped
my car keys in the parking lot, and I was saying, “Thank you,
thank you.” (Patient of NC)
[From an observational memorandum] The therapist demonstrated a masterful touch in doing a neck massage as she
prepared to do cervical traction with an outpatient. As she
carried out soft tissue work, her voice softened and her
conversation turned to items of personal interest to the
patient (rather than discussion of the patient’s health
problem). The therapist beamed with joy as the patient
responded to this touch by relaxing and allowing soft tissue
mobilization.
Virtues: Caring and Commitment
The dimension of virtues refers to personal character
traits and personal attributes we observed in the expert
therapists we studied. These experts all set high standards for themselves and were driven to stay current in
their specialty area. They were continually intrigued by
the challenges of clinical practice and strongly committed to doing what was best for the patient.
Physical Therapy . Volume 80 . Number 1 . January 2000
We have been in this community 15 years, and I know this
patient. I have this attitude that when people come to my
office, they become part of my family. (GC)
Discussion
The purpose of this study was to identify the dimensions
of expert practice in physical therapy across 4 specialty
areas using a series of qualitative case studies. The multiple
case study approach allowed us to build on the foundation provided by previous work on expertise1–3,19 –20 and
to generate grounded theory on expert practice in
physical therapy.28,35,36,40
Jensen et al . 39
Knowledge and Clinical Reasoning
Knowledge and clinical reasoning are both critical elements of expertise. One fundamental difference
between experts and novices is the knowledge they bring
to bear in solving problems.1,3 For these expert physical
therapists, the primary component for both the use of
knowledge and clinical reasoning was the centrality of
the patient. Although the knowledge they used in practice was multidimensional, the patient was a key source
of knowledge. We found our therapists engaged in
intensive listening to patients and working hard to
identify not only the movement problem but also what
would be necessary for the patient to succeed in overcoming the problem. They are proficient at selfmonitoring skills and know when to selectively gather
data or listen intently. When these peer-designated
expert clinicians were asked how they know what to do,
their responses were often related back to the patient
and their prior experiences with patients and families.
These therapists welcomed the challenge of tough cases
and were comfortable with uncertainty and ambiguity.
A growing body of expertise literature in physical
therapy15–20 and the professions41,42 emphasizes the
importance of metacognition, that is, self-monitoring
one’s thinking (cognition).3 Experts use this process in
order to detect inconsistencies or links between the data
gathered, what they know from experience, and a critique of their reasoning processes.3,42
We also witnessed a process of collaboration between
therapist and patient during the clinical reasoning process. The diagnostic process was not emphasized as a
central aspect of patient management; what counted was
patient function and understanding the context or the
social and psychological conditions and events that were
central to the patient’s world. Mattingly and Fleming,23
in their phenomenological work in clinical reasoning
among occupational therapists, described 3 modes of
reasoning: procedural, interactive, and conditional. Procedural reasoning represents the typical hypotheticodeductive approach of cue identification, hypothesis
generation, and evaluation. Interactive reasoning is the
reasoning that occurs during the encounter between the
patient and therapist as the therapist works to better
understand the patient. Conditional reasoning is a multidimensional process that involves the therapist’s reflection upon the clinical encounter from both procedural
and interactive views. We found little evidence among
our experts of a hypothetico-deductive approach in
reasoning, but our experts did demonstrate centering
on the patient, and a reflective process would appear to
be consistent with a conditional reasoning process.
Higgs and Jones43 argued that the key elements of
clinical reasoning are the use of knowledge, the act of
thinking (cognition), and the process of metacognition
40 . Jensen et al
(monitoring one’s thinking or reflection). In their interpretation of clinical reasoning, these core elements
occur throughout the reasoning process. In our study,
reflection was a critical element for our experts and the
means for their continued learning and development of
craft knowledge from their experience.
Movement: Central to Practice
Examination and evaluation of movement played a
central role in the clinical practice of these therapists.
The therapists displayed manual and observational skills
aimed at the assessment of patients’ functional movement. This assessment of movement dysfunction
through palpation, observation, or guiding the patient’s
body movement was an important aspect of the examination process across clinical specialties. The manual
skills of the therapist appeared to be a well-practiced,
almost “unconscious” part of their work, as their attention was often focused on dialogue with the patient or
family as they worked. Later, when therapists were
interviewed while watching videotapes of themselves
with the patient, they were able to describe in detail
exactly what they were doing with their own bodies, what
they felt with their hands, and their rationale for facilitating patient movement. Sometimes, they expressed
surprise at how much they were doing with their hands
and bodies while their attention was clearly directed
elsewhere. Facilitation of the patient’s movement or
motor performance was a critical part of prescribed
exercise and home programs. Exercise programs were
then directly linked to the patient’s function at home or
work. Finally, these therapists used touch as a powerful
communication tool to guide, stabilize, reassure, and
praise their patients.
The profession has had a long debate about whether
movement dysfunction is the unique aspect of the “discipline of physical therapy.”44 – 46 It appears that in
clinical practice, expert therapists demonstrate persistent, skillful manual and observational abilities centered
on functional movement specific to the individual
patient’s life needs.
Virtues
Our peer-designated experts had a strong inner drive to
succeed and continue to learn. In addition, they were
intellectually challenged by patients’ problems, had the
patients’ best interests in mind, and sought to solve the
problems, not judge the patients. We argue here that
these attributes are evidence of professional virtues.47
Brockett defined professional virtues as “those characteristics that contribute to trustworthy relationships
between. . .therapists, their clients, colleagues, employers, and the public. Examples are integrity, an attitude of
respect for other persons, and a willingness to put client
interests ahead of self-interest.”48(p201) Benner et al2
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asserted that ethical expertise is one dimension found in
professions where there are caring practices that include
recognition and respect for the other, mutual realization, and protection of vulnerability.
Purtilo49,50 contended that, although ethical duties and
rights provide the conceptual tools for recognizing and
resolving problems in everyday physical therapy practice,
the development of moral character assists in difficult,
complex situations. Furthermore, the larger framework
of mutual respect and care needs to be considered.
Our therapists shared common character traits as committed and caring professionals who hold ultimate
respect for their patients. Benner described the moral
dimension of clinical judgment well: “Clinical judgment
cannot be sound without knowing the patient’s/family’s
situation and moral concerns. The moral perception
cannot be astute without knowing and caring about the
patient/family.”51(p49)
Conception of Practice: Implications for the Profession
At the heart of our theoretical model of expert practice
is the therapist’s conception of physical therapy practice.
The conception of practice is not a single entity. The
elements of the 4 dimensions of expertise (ie, knowledge, reasoning, movement skills, and virtuous behavior) overlap and interplay to form this conception. Key
elements in the conception of practice include the role
of practical knowledge learned through listening to
patients and reflective practice, core beliefs about
patient-centered evaluation and treatment, collaborating with and teaching patients and families to maximize
function, skillful movement assessment through observation and manual skills, and shared commitment of
mutual respect and care. If expertise in physical therapy
is some combination of knowledge, judgment, movement, and virtue, can clinical practice and education be
designed in a manner to address these multiple dimensions of professional competence?
Our practice environments could find mechanisms to
provide the scarcest resource of all: time. Physical therapists need time with their patients, time with their
colleagues, time for reflection, and time to return to the
literature if they are to develop the knowledge-inpractice that results in becoming better and wiser clinicians. We suggest that managers consider placing a high
value on time for learning as an integral part of practice.
Just as physicians are expected to participate in rounds,
to review the literature, and to serve as clinical mentors,
physical therapists could also have these expectations.
Our therapists demonstrated complex clinical reasoning
skills centered on the patient they were treating but
using recall of pertinent information from the “data
Physical Therapy . Volume 80 . Number 1 . January 2000
bank” of previous similar cases. If the physical therapist
is seen entirely as a person who performs an initial
examination, designs a plan of care, and then turns that
patient over to another provider, then we deny that
therapist the opportunity to learn about the ongoing
changes that occur as a result of the clinical or teaching
interventions provided. Movement was also intimately
interwoven with clinical reasoning as our therapists used
data gathered from close observation and hands-on care
of patients as a primary source of knowledge. Continuity
of care provides the information base for clinical reasoning—learning from one patient to apply to the next
patient.
One of the most obvious things we learned from studying our therapists was their strong sense of commitment
to their patients and families and their continued personal quest for excellence. In addition, these therapists
are intrigued and challenged by patient care—they love
their work! We need to identify these expert clinicians in
our profession and encourage them to become the role
models and mentors for the next generation.
The stories of these expert clinicians provide a rich
stimulus for clinicians and educators to contemplate as
they plan for their own professional development or for
the development of students. Our work suggests that
there is a need for education to be rooted in practice,
taught around patient care by people who understand
both patient care and the relevance of scientific knowledge for the advancement of patient care and who value
the importance of lifelong learning and engage in
reflective practice that results in deliberative, moral
action. Practice by expert therapists also suggests the
following strategies be considered when teaching students: (1) teaching students to value the patient as
well as the clinical instructor as a source of knowledge,
(2) carefully listening to patients and understanding
the meanings patients hold about health and illness, and
(3) developing not only cognitive skills, but also the
ability to keenly observe and skillfully use one’s hands
and body to facilitate patients’ functional movements.
Development of these manual, practical skills will
require focused, intense practice as well as continuity of
practice. In addition, students need to learn reflectionin-action in every venue and to witness clinical instructors “thinking out loud” as they identify and solve patient
problems. Finally, students must learn to seek out and
value a wide spectrum of sources of knowledge and enjoy
the challenge of embedding this new knowledge in
everyday practice.
One of the most important physical therapy interventions valued by our experts was that of teaching patients
and families about their clinical problems and how to
Jensen et al . 41
care for themselves. For many of the experts, the success
of the total patient encounter rested on their abilities to
successfully teach the patient and the family. Thus,
students need knowledge and skills of effective teaching
and learning as well as to develop an understanding of
the difficult process of changing health behaviors. Students should be aware that a nonjudgmental approach
to patients is likely to enhance their effectiveness and
that collaboration with the patient is essential in designing treatment programs. Finally, our novice colleagues
need to be supported for exhibiting the virtues of caring,
compassion, and commitment. They need to witness
practitioners who demonstrate these virtues in practice
(eg, by assuming powerful patient advocacy roles) and
be challenged to emulate these virtues.
Future Research
Our theoretical model of expert practice in physical
therapy has been developed from our previous research,
existing theory on expertise, and the data from our
sample of therapists. The investigation involved multiple
researchers, multiple settings, and different clinical specialties. Although this diversity allowed numerous opportunities for conceptualization based on triangulation of
evidence, there is a need for more in-depth investigations in targeted areas. Further work is needed to
expand and refine the model across expert clinicians in
other clinical specialty areas.
We also suspect there are many therapists who demonstrate the dimensions of expert practice who do not fit
neatly into one specific clinical specialty area or who do
not necessarily reflect the same criteria we used to select
this sample. We need to study representative samples of
these therapists both to determine the relevance of the 4
dimensions to their style of practice and to gain a sense
of where and under what circumstances the experts in
our profession are practicing. Research also is needed to
determine whether experts have more effective patient
care outcomes than other therapists and what factors
may contribute to those outcomes. Finally, research is
needed on the development of clinical expertise. Why
do some therapists continue to develop into expert
clinicians, while other lapse into mediocrity?
Conclusion
We have outlined 4 major dimensions of expert practice
in physical therapy: knowledge, clinical reasoning, movement, and virtues. Each dimension was described using
supporting evidence from 4 composite case studies in 4
specialty areas of practice: geriatrics, neurology, orthopedics, and pediatrics. The identification of these
dimensions expands the traditional areas of expertise,
knowledge, and clinical reasoning and includes areas
specific to the physical therapists in our sample, the
central role of movement, and evidence of strong vir-
42 . Jensen et al
tues. Central to understanding the physical therapists we
studied was understanding their conception of clinical
practice. Their beliefs about what it means to be a
therapist, their goals for patients, and their beliefs about
the role of physical therapy in health care were at the
center of their practice.
Acknowledgments
We gratefully acknowledge the cooperation, sacrifice of
time, and reflective comments and responses from our
sample of clinicians. We also are indebted to their
patients who shared their time and allowed their treatment sessions to be videotaped.
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